Provider Demographics
NPI:1831122134
Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Entity Type:Organization
Organization Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Other - Org Name:VILLAGE MEDICAL ASSOCIATES
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:O
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:14366 SOMMERVILLE CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-6838
Mailing Address - Country:US
Mailing Address - Phone:804-794-5880
Mailing Address - Fax:804-379-4931
Practice Address - Street 1:14366 SOMMERVILLE CT
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113
Practice Address - Country:US
Practice Address - Phone:804-794-5880
Practice Address - Fax:804-379-4931
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS-VIRGINIA HEALTHSOURCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-09
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACI1391OtherRAILROAD MEDICARE
VACI1391OtherRAILROAD MEDICARE
VAC04469Medicare PIN