Basic Information
| Provider Information | |||||||||
| NPI: | 1881795557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | CROSSRIDGE PEDIATRICS & INTERNAL MEDICINE | ||||||||
| 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: | 10150 STAPLES MILL RD STE C | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230603452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047557581 | ||||||||
| FaxNumber: | 8047557586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | GAY | ||||||||
| AuthorizedOfficialFirstName: | WILBUR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8645617672 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 174400000X | 0101054649 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.