Provider Demographics
NPI:1922202571
Name:BON SECOURS DEPAUL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BON SECOURS DEPAUL MEDICAL CENTER INC
Other - Org Name:BON SECOURS TOWN CENTER MEDICAL ASSOCIATES
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 1:4421 VIRGINIA BEACH BLVD STE 114
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3114
Practice Address - Country:US
Practice Address - Phone:757-738-1300
Practice Address - Fax:757-687-3202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS DEPAUL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-14
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADD7037Medicare PIN
VAC06209Medicare PIN