Healthcare Provider Details

I. General information

NPI: 1972783918
Provider Name (Legal Business Name): BON SECOURS-VIRGINIA HEALTHSOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5207 HICKORY PARK DR SUITE A
GLEN ALLEN VA
23059
US

IV. Provider business mailing address

5207 HICKORY PARK DR SUITE A
GLEN ALLEN VA
23059-2624
US

V. Phone/Fax

Practice location:
  • Phone: 804-621-2980
  • Fax: 804-762-7102
Mailing address:
  • Phone: 804-621-2980
  • Fax: 804-762-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE O. BUTLER
Title or Position: DIRECTOR, CORPORATE RESPONSIBILITY
Credential: MBA
Phone: 804-281-0271