Provider Demographics
NPI:1962705061
Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CORPORATE RESPONSIBILITIES
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 1:304 E LEIGH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-1410
Mailing Address - Country:US
Mailing Address - Phone:804-225-7148
Mailing Address - Fax:804-225-7159
Practice Address - Street 1:304 E LEIGH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1410
Practice Address - Country:US
Practice Address - Phone:804-225-7148
Practice Address - Fax:804-225-7159
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-10
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101226755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06115OtherGROUP PTAN
VAC06115OtherGROUP PTAN