Basic Information
| Provider Information | |||||||||
| NPI: | 1609267053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENTARA MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | SENTARA INFECTIOUS DISEASE SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 RIVERVIEW AVE | ||||||||
| Address2: | STE 710 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235101065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572529040 | ||||||||
| FaxNumber: | 7572529041 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 RIVERVIEW AVE | ||||||||
| Address2: | STE 710 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235101065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572529040 | ||||||||
| FaxNumber: | 7572529041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2015 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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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 | 207RI0200X | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | C02033 | 01 | VA | MEDICARE GROUP NUMBER | OTHER |