Basic Information
| Provider Information | |||||||||
| NPI: | 1245514017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER INC | ||||||||
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| OtherOrganizationName: | THE BON SECOURS WOUND CARE CENTER AT MEMORIAL REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8580 MAGELLAN PKWY | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232271149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046275462 | ||||||||
| FaxNumber: | 8664490896 | ||||||||
| Practice Location | |||||||||
| Address1: | 8237 MEADOWBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231162329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048938540 | ||||||||
| FaxNumber: | 8045590225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2011 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | QUIRICONI | ||||||||
| AuthorizedOfficialFirstName: | STEPHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8042818301 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | H1831 | VA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1912969064 | 05 | VA | MEDICAID |