MEDICARE: BON SECOURS DEPAUL MEDICAL CENTER 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1144630450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BON SECOURS DEPAUL MEDICAL CENTER INC

Provider Business Mailing Address
First Line	:	8580 MAGELLAN PKWY
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-1149
Country	:	US
Telephone Number	:	804-627-5462
Fax Number	:	866-449-0896

Provider Business Practice Location Address
First Line	:	4421 VIRGINIA BEACH BLVD STE 114
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-3114
Country	:	US
Telephone Number	:	757-738-1300
Fax Number	:	757-687-3202

Authorized Official
Title or Position	:	CFO
Name	:	STEPHAN QUIRICONI
Credential	:
Telephone Number	:	804-281-8301

Provider Enumeration Date	:	05/08/2014
Last Update Date	:	05/16/2019

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