Provider Demographics
NPI:1770730475
Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Entity type:Organization
Organization Name:BON SECOURS-VIRGINIA HEALTHSOURCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CORP RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ODELL
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:7001 FOREST AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1726
Mailing Address - Country:US
Mailing Address - Phone:804-287-3550
Mailing Address - Fax:804-281-7840
Practice Address - Street 1:7001 FOREST AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230
Practice Address - Country:US
Practice Address - Phone:804-287-3550
Practice Address - Fax:804-281-7840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-25
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056520207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06695Medicare PIN