Provider Demographics
NPI:1902132095
Name:BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.
Entity Type:Organization
Organization Name:BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.
Other - Org Name:BON SECOURS ST. MARY'S HOSPITAL HEART AND VASCULAR INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CORP RESPONSIBILITY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ODELL
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-281-0271
Mailing Address - Street 1:5801 BREMO RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1907
Mailing Address - Country:US
Mailing Address - Phone:804-287-7282
Mailing Address - Fax:804-287-7275
Practice Address - Street 1:7001 FOREST AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1726
Practice Address - Country:US
Practice Address - Phone:804-287-7282
Practice Address - Fax:804-287-7275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1833261QR0404X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac Facilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4900596Medicaid
VA4900596Medicaid