Provider Demographics
NPI:1548520315
Name:BON SECOURS DEPAUL MEDICAL CENTER
Entity type:Organization
Organization Name:BON SECOURS DEPAUL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:KERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-673-5929
Mailing Address - Street 1:100 KINGSLEY LN
Mailing Address - Street 2:SUITE 404
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4604
Mailing Address - Country:US
Mailing Address - Phone:757-889-5632
Mailing Address - Fax:757-889-5633
Practice Address - Street 1:100 KINGSLEY LN
Practice Address - Street 2:SUITE 404
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4604
Practice Address - Country:US
Practice Address - Phone:757-889-5632
Practice Address - Fax:757-889-5633
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS DEPAUL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-25
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06209Medicare PIN