Provider Demographics
NPI:1437182094
Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLC
Other - Org Name:AYLETT MEDICAL 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:864-561-7672
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:
Mailing Address - Fax:866-449-0896
Practice Address - Street 1:1041 SHARON RD STE 205
Practice Address - Street 2:
Practice Address - City:KING WILLIAM
Practice Address - State:VA
Practice Address - Zip Code:23086-3344
Practice Address - Country:US
Practice Address - Phone:804-769-3096
Practice Address - Fax:804-769-3170
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-08
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACN2764OtherRAILROAD MEDICARE
VAB09441Medicare UPIN
VA490069Medicare Oscar/Certification
VACN2764OtherRAILROAD MEDICARE