Provider Demographics
NPI:1043243546
Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Entity Type:Organization
Organization Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Other - Org Name:DOMINION FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CORP RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ODELL
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:4835 S LABURNUM AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-2713
Mailing Address - Country:US
Mailing Address - Phone:804-226-4141
Mailing Address - Fax:804-226-4142
Practice Address - Street 1:4835 S LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231
Practice Address - Country:US
Practice Address - Phone:804-226-4141
Practice Address - Fax:804-226-4142
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS-VIRGINIA HEALTHSOURCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-08
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACB2823OtherRAILROAD MEDICARE
VACB2823OtherRAILROAD MEDICARE
VAH43288Medicare UPIN