1740618412 NPI number — BON SECOURS DEPAUL MEDICAL CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740618412 NPI number — BON SECOURS DEPAUL MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BON SECOURS DEPAUL MEDICAL CENTER
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 CONTEMPORARY MEDICINE
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:
1740618412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 GRESHAM DR
Provider Second Line Business Mailing Address:
SUITE 808
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23507-1901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-622-7998
Provider Business Mailing Address Fax Number:
757-215-2729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 GRESHAM DR
Provider Second Line Business Practice Location Address:
SUITE 808
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23507-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-622-7998
Provider Business Practice Location Address Fax Number:
757-215-2729
Provider Enumeration Date:
10/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KERNER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHEIF EXECUTIVE OFFICER
Authorized Official Telephone Number:
757-673-5920

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C06209 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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