Basic Information
Provider Information | |||||||||
NPI: | 1821350323 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BON SECOURS ST. MARY'S HOSPITAL WOUND CARE CENTER AT REYNOLDS CROSSING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6900 FOREST AVE | ||||||||
Address2: | SUITE 115 | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232301701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8048938710 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6900 FOREST AVE | ||||||||
Address2: | SUITE 115 | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232301701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8048938710 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2012 | ||||||||
LastUpdateDate: | 10/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUTLER | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: | ODELL | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CORP RESPONSIBILITY | ||||||||
AuthorizedOfficialTelephone: | 8042810271 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BON SECOURS ST. MARY'S HOSPITAL OF RICHMOND INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | H1833 | VA | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 1962464016 | 05 | VA |   | MEDICAID |