Basic Information
| Provider Information | |||||||||
| NPI: | 1669638037 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BON SECOURS-VIRGINIA HEALTHSOURCE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMONWEALTH SURGEONS - BON SECOURS MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5855 BREMO RD | ||||||||
| Address2: | SUITE 506 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232261930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042853225 | ||||||||
| FaxNumber: | 8042850360 | ||||||||
| Practice Location | |||||||||
| Address1: | 5855 BREMO RD | ||||||||
| Address2: | SUITE 506 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042853225 | ||||||||
| FaxNumber: | 8042850360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | O. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, CORPORATE RESPONSIBILITY | ||||||||
| AuthorizedOfficialTelephone: | 8042810271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BON SECOURS-VIRGINIA HEALTHSOURCE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.