Provider Demographics
NPI:1215216387
Name:BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.
Entity Type:Organization
Organization Name:BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.
Other - Org Name:BON SECOURS PEDIATRIC INFECTIOUS DISEASE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR. CORP. RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:O
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:5875 BREMO RD STE 303
Mailing Address - Street 2:MOB SOUTH
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1934
Mailing Address - Country:US
Mailing Address - Phone:804-977-8914
Mailing Address - Fax:804-281-0950
Practice Address - Street 1:5875 BREMO RD STE 303
Practice Address - Street 2:MOB SOUTH
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-977-8914
Practice Address - Fax:804-281-0950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN