1962633149 NPI number — BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.

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 1962633149 NPI number — BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, 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:
DOMINION SURGICAL ASSOCIATES - BON SECOURS MEDICAL 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:
1962633149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5855 BREMO RD
Provider Second Line Business Mailing Address:
MOB NORTH, SUITE 406
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23226-1930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-285-4133
Provider Business Mailing Address Fax Number:
804-622-2224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5855 BREMO RD
Provider Second Line Business Practice Location Address:
MOB NORTH, SUITE 406
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23226-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-285-4133
Provider Business Practice Location Address Fax Number:
804-622-2224
Provider Enumeration Date:
08/05/2009

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C06778 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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