Basic Information
| Provider Information | |||||||||
| NPI: | 1114107729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENTARA MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UROLOGY OF VIRGINIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2502 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235012502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574813556 | ||||||||
| FaxNumber: | 7574963865 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 FIRST COLONIAL RD | ||||||||
| Address2: | STE 100G | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234542207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574813556 | ||||||||
| FaxNumber: | 7574963865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2007 | ||||||||
| LastUpdateDate: | 02/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7576871076 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.