1588697148 NPI number — BON SECOURS-VIRGINIA HEALTHSOURCE, INC.

Table of content: (NPI 1588697148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588697148 NPI number — BON SECOURS-VIRGINIA HEALTHSOURCE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BON SECOURS-VIRGINIA HEALTHSOURCE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BROOK RUN FAMILY PHYSICIANS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588697148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8580 MAGELLAN PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23227-1149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
866-449-0896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10571 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
GLEN ALLEN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-266-7611
Provider Business Practice Location Address Fax Number:
804-262-9249
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
QUIRICONI
Authorized Official First Name:
STEPHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
804-281-8301

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CB2823 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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