Provider Demographics
NPI:1821350323
Name:BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.
Entity Type:Organization
Organization Name:BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.
Other - Org Name:BON SECOURS ST. MARY'S HOSPITAL WOUND CARE CENTER AT REYNOLDS CROSSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CORP RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ODELL
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:6900 FOREST AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1701
Mailing Address - Country:US
Mailing Address - Phone:804-893-8710
Mailing Address - Fax:
Practice Address - Street 1:6900 FOREST AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1701
Practice Address - Country:US
Practice Address - Phone:804-893-8710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS ST. MARY'S HOSPITAL OF RICHMOND INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-11
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1833261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1962464016Medicaid
VA490059Medicare Oscar/Certification