Provider Demographics
NPI:1770643835
Name:BON SECOURS DEPAUL MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:BON SECOURS DEPAUL MEDICAL CENTER LLC
Other - Org Name:BON SECOURS DEPAUL MEDICAL CENTER CRNA
Other - Org Type:Other Name
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 1:150 KINGSLEY LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4602
Practice Address - Country:US
Practice Address - Phone:757-889-5155
Practice Address - Fax:757-889-4127
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS DEPAUL MEDICAL CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-11
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06209Medicare PIN