Provider Demographics
NPI:1912109497
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, CORPORATE RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:O
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:8220 MEADOWBRIDGE RD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2336
Mailing Address - Country:US
Mailing Address - Phone:804-764-7686
Mailing Address - Fax:804-764-7689
Practice Address - Street 1:8220 MEADOWBRIDGE RD
Practice Address - Street 2:SUITE 308
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116
Practice Address - Country:US
Practice Address - Phone:804-764-7686
Practice Address - Fax:804-764-7689
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS-VIRGINIA HEALTHSOURCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-05
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06695OtherGROUP PTAN
VAC06695OtherGROUP PTAN