Healthcare Provider Details

I. General information

NPI: 1205246519
Provider Name (Legal Business Name): BON SECOURS DEPAUL MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 EDEN WAY N STE 100
CHESAPEAKE VA
23320-3336
US

IV. Provider business mailing address

8580 MAGELLAN PKWY
RICHMOND VA
23227-1149
US

V. Phone/Fax

Practice location:
  • Phone: 757-738-1350
  • Fax: 757-413-5450
Mailing address:
  • Phone: 804-627-5462
  • Fax: 866-449-0896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHAN QUIRICONI
Title or Position: CFO
Credential:
Phone: 804-281-8301