Provider Demographics
NPI:1194878348
Name:BON SECOURS DEPAUL MEDICAL CENTER CRNA
Entity type:Organization
Organization Name:BON SECOURS DEPAUL MEDICAL CENTER CRNA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPC
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-889-5109
Mailing Address - Street 1:PO BOX
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8424
Mailing Address - Country:US
Mailing Address - Phone:757-889-5109
Mailing Address - Fax:757-889-2550
Practice Address - Street 1:150 KINGSLEY LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4602
Practice Address - Country:US
Practice Address - Phone:757-889-5109
Practice Address - Fax:757-889-2550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05025Medicare PIN