NPIMap

Organization Active NPI

Bon Secours-St. Mary's Hospital of Richmond, Inc.

Doing business as Glen Allen Internal Medicine

  • Internal Medicine Physician
  • Glen Allen, VA
National Provider Identifier
1063799302
Registry record updated Oct 24, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.
Doing business as
Glen Allen Internal Medicine
Practice address
5207 Hickory Park Dr
Suite a
Glen Allen, VA 23059-2624
Phone
(804) 612-2980
Fax
(804) 762-7102
NPI assigned
Nov 15, 2011
Last updated
Oct 24, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 24, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
George O Butler
Title
Director Corporate Responsibility
Phone
(804) 281-0271

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X NU Primary

Addresses

Primary practice location

5207 Hickory Park Dr
Suite a
Glen Allen, VA 23059-2624

Mailing address

5207 Hickory Park Dr
Suite a
Glen Allen, VA 23059-2624
Phone (804) 612-2980

Other identifiers 1

IdentifierTypeStateIssuer
C06778OtherVAGROUP PTAN

Other names 1

  • Glen Allen Internal Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040324000566 VA Part B Supplier - Clinic/Group Practice 8527969476 Receives reassigned benefits from 159 practitioners
48 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Richmond, VA; Midlothian, VA; Mechanicsville, VA; Chester, VA; Blackstone, VA

Other NPIs on the same Medicare enrollment 48

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 48

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1321315200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1540339200000",
    "number": "1063799302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5207 HICKORY PARK DR",
            "address_2": "SUITE A",
            "city": "GLEN ALLEN",
            "state": "VA",
            "postal_code": "230592624",
            "telephone_number": "804-612-2980",
            "fax_number": "804-762-7102"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5207 HICKORY PARK DR",
            "address_2": "SUITE A",
            "city": "GLEN ALLEN",
            "state": "VA",
            "postal_code": "230592624",
            "telephone_number": "804-612-2980",
            "fax_number": "804-762-7102"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BON SECOURS-ST. MARY'S HOSPITAL OF RICHMOND, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-11-15",
        "last_updated": "2018-10-24",
        "status": "A",
        "authorized_official_last_name": "BUTLER",
        "authorized_official_first_name": "GEORGE",
        "authorized_official_middle_name": "O",
        "authorized_official_title_or_position": "DIRECTOR CORPORATE RESPONSIBILITY",
        "authorized_official_telephone_number": "804-281-0271"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP PTAN",
            "identifier": "C06778",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Glen Allen Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Glen Allen Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Glen Allen, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.