Basic Information
| Provider Information | |||||||||
| NPI: | 1851573141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENTARA MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UROLOGY OF VIRGINIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 COLISEUM DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236665906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577368500 | ||||||||
| FaxNumber: | 7572241799 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 COLISEUM DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236665906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577368500 | ||||||||
| FaxNumber: | 7572241799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 04/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | HINES | ||||||||
| AuthorizedOfficialFirstName: | ARRIE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7572523339 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.