Provider Demographics
NPI:1619304789
Name:BON SECOURS VIRGINIA MEDICAL GROUP I, LLC
Entity Type:Organization
Organization Name:BON SECOURS VIRGINIA MEDICAL GROUP I, LLC
Other - Org Name:BON SECOURS GOOD HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR CORPORATE RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:5875 BREMO RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1934
Mailing Address - Country:US
Mailing Address - Phone:804-977-8915
Mailing Address - Fax:804-288-1326
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:SUITE 204
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-977-8915
Practice Address - Fax:804-288-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty