Provider Demographics
NPI:1669638037
Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Entity Type:Organization
Organization Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Other - Org Name:COMMONWEALTH SURGEONS - BON SECOURS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, CORPORATE RESPONSIBILITY
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:O
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:5855 BREMO RD
Mailing Address - Street 2:SUITE 506
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1930
Mailing Address - Country:US
Mailing Address - Phone:804-285-3225
Mailing Address - Fax:804-285-0360
Practice Address - Street 1:5855 BREMO RD
Practice Address - Street 2:SUITE 506
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226
Practice Address - Country:US
Practice Address - Phone:804-285-3225
Practice Address - Fax:804-285-0360
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS-VIRGINIA HEALTHSOURCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-05
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06695Medicare PIN