Provider Demographics
NPI:1114542453
Name:BON SECOURS MEDICAL GROUP HAMPTON ROADS SPECIALTY CARE LLC
Entity Type:Organization
Organization Name:BON SECOURS MEDICAL GROUP HAMPTON ROADS SPECIALTY CARE LLC
Other - Org Name:SOUTHAMPTON ORTHOPAEDIC AND SPORTS MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-255-1904
Mailing Address - Street 1:8580 MAGELLAN PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1149
Mailing Address - Country:US
Mailing Address - Phone:866-496-9229
Mailing Address - Fax:866-449-0896
Practice Address - Street 1:6 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1240
Practice Address - Country:US
Practice Address - Phone:757-562-7301
Practice Address - Fax:757-562-7305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-12
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty