Provider Demographics
NPI:1972783918
Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Entity Type:Organization
Organization Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Other - Org Name:GLEN ALLEN INTERNAL MEDICINE
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 1:5207 HICKORY PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-2624
Mailing Address - Country:US
Mailing Address - Phone:804-621-2980
Mailing Address - Fax:804-762-7102
Practice Address - Street 1:5207 HICKORY PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059
Practice Address - Country:US
Practice Address - Phone:804-621-2980
Practice Address - Fax:804-762-7102
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS-VIRGINIA HEALTHSOURCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-07
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06695Medicare PIN