Basic Information
| Provider Information | |||||||||
| NPI: | 1922772813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SENTARA MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 824 N MILITARY HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883198 | ||||||||
| FaxNumber: | 8334700791 | ||||||||
| Practice Location | |||||||||
| Address1: | 824 N MILITARY HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235023652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883198 | ||||||||
| FaxNumber: | 8334700791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | PRINCE | ||||||||
| AuthorizedOfficialFirstName: | DORIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7579835475 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.