Healthcare Provider Details

I. General information

NPI: 1548293194
Provider Name (Legal Business Name): BON SECOURS-VIRGINIA HEALTHSOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 N MAIN ST
BLACKSTONE VA
23824
US

IV. Provider business mailing address

213 N MAIN ST
BLACKSTONE VA
23824-1425
US

V. Phone/Fax

Practice location:
  • Phone: 434-292-7261
  • Fax: 434-298-0908
Mailing address:
  • Phone: 434-292-7261
  • Fax: 434-298-0908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE O BUTLER
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 804-281-0271