Provider Demographics
NPI:1730416579
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 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 1:1500 N 28TH ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-5332
Mailing Address - Country:US
Mailing Address - Phone:804-371-1675
Mailing Address - Fax:804-225-1764
Practice Address - Street 1:1500 N 28TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5332
Practice Address - Country:US
Practice Address - Phone:804-371-1675
Practice Address - Fax:804-225-1764
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-16
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06115OtherGROUP PTAN
VA490069Medicare Oscar/Certification