Basic Information
Provider Information | |||||||||
NPI: | 1265954747 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SENTARA MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SENTARA CARDIOLOGY SPECIALISTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1933 EDWIN DR STE 208A | ||||||||
Address2: |   | ||||||||
City: | CHESAPEAKE | ||||||||
State: | VA | ||||||||
PostalCode: | 233226531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572525660 | ||||||||
FaxNumber: | 7572047788 | ||||||||
Practice Location | |||||||||
Address1: | 1933 EDWIN DR STE 208A | ||||||||
Address2: |   | ||||||||
City: | CHESAPEAKE | ||||||||
State: | VA | ||||||||
PostalCode: | 233226531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572525660 | ||||||||
FaxNumber: | 7572047788 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAYLOR | ||||||||
AuthorizedOfficialFirstName: | CINDY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7572522765 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | C02033 | 01 | VA | MEDICARE | OTHER |