Basic Information
| Provider Information | |||||||||
| NPI: | 1821358144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENTARA MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | SENTARA CARDIOLOGY SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 RIVERVIEW AVE | ||||||||
| Address2: | STE 700 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235101065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572529365 | ||||||||
| FaxNumber: | 7579627217 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 RIVERVIEW AVE | ||||||||
| Address2: | STE 700 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235101065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572529365 | ||||||||
| FaxNumber: | 7579627217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2012 | ||||||||
| LastUpdateDate: | 06/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7572523344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | C02033 | 01 | VA | MEDICARE GROUP NUMBER | OTHER |