Basic Information
| Provider Information | |||||||||
| NPI: | 1508240326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENTARA MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | SENTARA PRATT MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12101 CAROL LN | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224076101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407857810 | ||||||||
| FaxNumber: | 5407863099 | ||||||||
| Practice Location | |||||||||
| Address1: | 12101 CAROL LN | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224076101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407857810 | ||||||||
| FaxNumber: | 5407863099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2015 | ||||||||
| LastUpdateDate: | 07/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7572522765 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | VA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | VA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 225100000X | VA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 332B00000X | VA | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207Q00000X | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | C02033 | 01 | VA | MEDICARE GROUP NUMBER | OTHER |