Provider Demographics
NPI:1881795557
Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLC
Entity type:Organization
Organization Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-561-7672
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:
Mailing Address - Fax:866-449-0896
Practice Address - Street 1:10150 STAPLES MILL RD STE C
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3452
Practice Address - Country:US
Practice Address - Phone:804-755-7581
Practice Address - Fax:804-755-7586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RA0000X, 208000000X
VA0101054649174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA490069Medicare Oscar/Certification
VAC06115Medicare PIN