Provider Demographics
NPI:1962633149
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:DOMINION SURGICAL ASSOCIATES - BON SECOURS MEDICAL GROUP
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 1:5855 BREMO RD
Mailing Address - Street 2:MOB NORTH, SUITE 406
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1930
Mailing Address - Country:US
Mailing Address - Phone:804-285-4133
Mailing Address - Fax:804-622-2224
Practice Address - Street 1:5855 BREMO RD
Practice Address - Street 2:MOB NORTH, SUITE 406
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1930
Practice Address - Country:US
Practice Address - Phone:804-285-4133
Practice Address - Fax:804-622-2224
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-05
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
VAC06778OtherGROUP PTAN