Provider Demographics
NPI:1922054287
Name:BON SECOURS DEPAUL MEDICAL CENTER IMAGE RECOVERY CENTER
Entity Type:Organization
Organization Name:BON SECOURS DEPAUL MEDICAL CENTER IMAGE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUGGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-889-5851
Mailing Address - Street 1:150 KINGSLEY LN
Mailing Address - Street 2:/SUITE #1 - IMAGE RECOVERY CENTER
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4602
Mailing Address - Country:US
Mailing Address - Phone:757-889-5795
Mailing Address - Fax:757-889-5820
Practice Address - Street 1:150 KINGSLEY LN
Practice Address - Street 2:/SUITE #1 - IMAGE RECOVERY CENTER
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4602
Practice Address - Country:US
Practice Address - Phone:757-889-5795
Practice Address - Fax:757-889-5820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1202014479332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9109404Medicaid
VA9109404Medicaid