Basic Information
| Provider Information | |||||||||
| NPI: | 1326026451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 COLISEUM DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236665906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574523441 | ||||||||
| FaxNumber: | 7572241799 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 COLISEUM DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236665906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574523441 | ||||||||
| FaxNumber: | 7572241799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0101050661 | VA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 007502532 | 05 | VA | MEDICAID | 55957 | 01 | VA | SENTARA HEALTHCARE | OTHER | 326593 | 01 | VA | ANTHEM BC BS | OTHER |