Provider Demographics
NPI:1336520618
Name:BON SECOURS DEPAUL MEDICAL CENTER
Entity Type:Organization
Organization Name:BON SECOURS DEPAUL MEDICAL CENTER
Other - Org Name:BON SECOURS FASTCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-215-2784
Mailing Address - Street 1:7007 HARBOUR VIEW BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3657
Mailing Address - Country:US
Mailing Address - Phone:757-215-2784
Mailing Address - Fax:
Practice Address - Street 1:309 BATTLEFIELD BLVD S
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-5311
Practice Address - Country:US
Practice Address - Phone:757-215-2777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C06209Medicare PIN