Provider Demographics
NPI:1740618412
Name:BON SECOURS DEPAUL MEDICAL CENTER
Entity Type:Organization
Organization Name:BON SECOURS DEPAUL MEDICAL CENTER
Other - Org Name:BON SECOURS CONTEMPORARY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-673-5920
Mailing Address - Street 1:400 GRESHAM DR
Mailing Address - Street 2:SUITE 808
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1901
Mailing Address - Country:US
Mailing Address - Phone:757-622-7998
Mailing Address - Fax:757-215-2729
Practice Address - Street 1:400 GRESHAM DR
Practice Address - Street 2:SUITE 808
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1901
Practice Address - Country:US
Practice Address - Phone:757-622-7998
Practice Address - Fax:757-215-2729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06209OtherGROUP PTAN