Basic Information
| Provider Information | |||||||||
| NPI: | 1083841936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BON SECOURS ST FRANCIS MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | THE WOUND CENTER AT ST. FRANCIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8580 MAGELLAN PKWY | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232271149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8664490896 | ||||||||
| Practice Location | |||||||||
| Address1: | 13700 ST FRANCIS BLVD STE 303 | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231143222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045947456 | ||||||||
| FaxNumber: | 8045947457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | RALSTON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SYSTEM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4199965119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BON SECOURS ST. FRANCIS MEDICAL CENTER LLC | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | C09633 | 01 | VA | GROUP PTAN | OTHER |