Provider Demographics
NPI:1588697148
Name:BON SECOURS-VIRGINIA HEALTHSOURCE, INC.
Entity type:Organization
Organization Name:BON SECOURS-VIRGINIA HEALTHSOURCE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIRICONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-8301
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 1:10571 TELEGRAPH RD
Practice Address - Street 2:SUITE 130
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059
Practice Address - Country:US
Practice Address - Phone:804-266-7611
Practice Address - Fax:804-262-9249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACB2823OtherRAILROAD MEDICARE
VAB08908Medicare UPIN
VAC06734Medicare PIN