Basic Information
| Provider Information | |||||||||
| NPI: | 1699906875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BON SECOURS ST MARY'S HOSPITAL OF RICHMOND LLC | ||||||||
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| OtherOrganizationName: | PEDIATRIC LUNG CARE - BON SECOURS MEDICAL GROUP | ||||||||
| 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: | 5875 BREMO RD STE 104 | ||||||||
| Address2: | MOB SOUTH | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232261934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042877770 | ||||||||
| FaxNumber: | 8042877801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2009 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | GAY | ||||||||
| AuthorizedOfficialFirstName: | WILBUR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8645617672 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BON SECOURS ST MARY'S HOSPITAL OF RICHMOND LLC | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | C06778 | 01 | VA | GROUP PTAN | OTHER |