Provider Demographics
NPI:1912209149
Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER INC
Other - Org Name:BON SECOURS CAPITOL OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIRICONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-8301
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:804-627-5462
Mailing Address - Fax:866-449-0896
Practice Address - Street 1:1510 N 28TH ST
Practice Address - Street 2:SUITE 305
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5311
Practice Address - Country:US
Practice Address - Phone:804-371-1689
Practice Address - Fax:804-371-1678
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-19
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06115OtherGROUP PTAN
VA490069Medicare Oscar/Certification