Basic Information
| Provider Information | |||||||||
| NPI: | 1124036629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BON SECOURS-VIRGINIA HEALTHSOURCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BON SECOURS HOME MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7229 FOREST AVE | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232263765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042810271 | ||||||||
| FaxNumber: | 8045219367 | ||||||||
| Practice Location | |||||||||
| Address1: | 8143 STAPLES MILL RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042662002 | ||||||||
| FaxNumber: | 8042661025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | ODELL | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CORP RESPONSIBILITY | ||||||||
| AuthorizedOfficialTelephone: | 8042810271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 070942 | 01 | VA | ANTHEM BCBS OF VA | OTHER | 0897250 | 01 | VA | AETNA | OTHER | 009135162 | 05 | VA | MEDICAID | 189262 | 01 | VA | SOUTHERN HEALTH | OTHER | 20650 | 01 | VA | OPTIMA HEALTH | OTHER |