Healthcare Provider Details

I. General information

NPI: 1174164578
Provider Name (Legal Business Name): BON SECOURS MEDICAL GROUP HAMPTON ROADS SPECIALTY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 HIGH ST STE 1F
PORTSMOUTH VA
23707-3213
US

IV. Provider business mailing address

8580 MAGELLAN PKWY
RICHMOND VA
23227-1149
US

V. Phone/Fax

Practice location:
  • Phone: 757-215-3565
  • Fax: 757-397-8026
Mailing address:
  • Phone:
  • Fax: 866-449-0896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN JONES
Title or Position: VP OPERATIONS
Credential:
Phone: 757-215-2713