Provider Demographics
NPI:1225263940
Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER
Other - Org Name:RICHMOND DIABETES AND ENDOCRINOLOGY - BON SECOURS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIRICONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-8301
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:804-627-5462
Mailing Address - Fax:866-449-0896
Practice Address - Street 1:8266 ATLEE RD STE 332
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1812
Practice Address - Country:US
Practice Address - Phone:804-764-7686
Practice Address - Fax:804-764-7689
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-26
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06115OtherGROUP PTAN
VA490069Medicare Oscar/Certification