MEDICARE: BON SECOURS-VIRGINIA HEALTHSOURCE 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		VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CG5286	OTHER	VA	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1801829205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BON SECOURS-VIRGINIA HEALTHSOURCE 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	:	1510 N 28TH ST STE 308
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-5311
Country	:	US
Telephone Number	:	804-644-1665
Fax Number	:	804-644-5285

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	06/11/2019

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