=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407889082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BON SECOURS-VIRGINIA HEALTHSOURCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 07/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9220 FOREST HILL AVE SUITE 1-A
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-560-8838
-----------------------------------------------------
Fax | 804-560-3527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9220 FOREST HILL AVE SUITE 1-A
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-6800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-560-8838
-----------------------------------------------------
Fax | 804-560-3527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, CORPORATE RESPONSIBILITY
-----------------------------------------------------
Name | GEORGE O. BUTLER
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 804-281-0271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------