Basic Information
Provider Information
NPI: 1740617679
EntityType: 2
ReplacementNPI:  
OrganizationName: BON SECOURS VIRGINIA MEDICAL GROUP I, LLC
LastName:  
FirstName:  
MiddleName:  
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Credential:  
OtherOrganizationName: PEDIATRIC LUNG CARE- BSMG
OtherOrganizationType: 3
OtherLastName:  
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Mailing Information
Address1: 5875 BREMO RD
Address2: SUITE 303
City: RICHMOND
State: VA
PostalCode: 232261934
CountryCode: US
TelephoneNumber: 8042818303
FaxNumber: 8042877801
Practice Location
Address1: 5875 BREMO RD
Address2: SUITE 303
City: RICHMOND
State: VA
PostalCode: 232261934
CountryCode: US
TelephoneNumber: 8042818303
FaxNumber: 8042877801
Other Information
ProviderEnumerationDate: 10/10/2013
LastUpdateDate: 10/10/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: BUTLER
AuthorizedOfficialFirstName: GEORGE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: DIRECTOR CORPORATE RESPONSIBILITY
AuthorizedOfficialTelephone: 8042810271
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2080P0214X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology

No ID Information.


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