MEDICARE: BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C06778	OTHER	VA	GROUP PTAN

General Provider Information

NPI Number	:	1063799302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.

Provider Business Mailing Address
First Line	:	5207 HICKORY PARK DR
Second Line	:	SUITE A
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-2624
Country	:	US
Telephone Number	:	804-612-2980
Fax Number	:	804-762-7102

Provider Business Practice Location Address
First Line	:	5207 HICKORY PARK DR
Second Line	:	SUITE A
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-2624
Country	:	US
Telephone Number	:	804-612-2980
Fax Number	:	804-762-7102

Authorized Official
Title or Position	:	DIRECTOR CORPORATE RESPONSIBILITY
Name	:	GEORGE O BUTLER
Credential	:
Telephone Number	:	804-281-0271

Provider Enumeration Date	:	11/15/2011
Last Update Date	:	10/24/2018

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