1457788358 NPI number — BON SECOURS VIRGINIA MEDICAL GROUP I, LLC

Table of content: (NPI 1457788358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457788358 NPI number — BON SECOURS VIRGINIA MEDICAL GROUP I, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BON SECOURS VIRGINIA MEDICAL GROUP I, LLC
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:
BON SECOURS BEHAVIORAL HEALTH GROUP
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:
1457788358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 N 28TH ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23223-5311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-371-1670
Provider Business Mailing Address Fax Number:
804-371-1671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 N 28TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23223-5311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-371-1670
Provider Business Practice Location Address Fax Number:
804-371-1671
Provider Enumeration Date:
10/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BUTLER
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR CORPORATE RESPONSIBILITY
Authorized Official Telephone Number:
804-281-0271

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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