1568918480 NPI number — SENTARA MEDICAL GROUP

Table of content: (NPI 1568918480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568918480 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:
Provider Other Organization Name Type Code:
6
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:
1568918480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2790 GODWIN BLVD
Provider Second Line Business Mailing Address:
STE 355
Provider Business Mailing Address City Name:
SUFFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23434-8151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-983-8520
Provider Business Mailing Address Fax Number:
757-579-8643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2790 GODWIN BLVD
Provider Second Line Business Practice Location Address:
STE 355
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23434-8151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-983-8520
Provider Business Practice Location Address Fax Number:
757-579-8643
Provider Enumeration Date:
08/31/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
757-252-2765

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: C02033 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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