1255096442 NPI number — SENTARA MEDICAL GROUP

Table of content: (NPI 1255096442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255096442 NPI number — SENTARA MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENTARA MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SENTARA BEHAVIORAL HEALTH CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255096442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3388 PRINCESS ANNE RD STE 2001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23456-2612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-507-7270
Provider Business Mailing Address Fax Number:
757-227-5055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3388 PRINCESS ANNE RD STE 2001
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23456-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-507-7270
Provider Business Practice Location Address Fax Number:
757-227-5055
Provider Enumeration Date:
11/03/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PRINCE
Authorized Official First Name:
DORIS
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
757-983-5475

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084B0040X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)