Basic Information
Provider Information | |||||||||
NPI: | 1548529126 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BON SECOURS PEDIATRIC GASTROENTEROLOGY ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8580 MAGELLAN PKWY | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232271149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8046275462 | ||||||||
FaxNumber: | 8664490896 | ||||||||
Practice Location | |||||||||
Address1: | 5855 BREMO RD STE 605 | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232261926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8042818303 | ||||||||
FaxNumber: | 8042877801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2012 | ||||||||
LastUpdateDate: | 02/13/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | QUIRICONI | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 8042818301 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | C06778 | 01 | VA | GROUP PTAN | OTHER |