Provider Demographics
NPI:1487694345
Name:BON SECOURS CHARITY HEALTH SYSTEM MEDICAL GROUP, P.C.
Entity type:Organization
Organization Name:BON SECOURS CHARITY HEALTH SYSTEM MEDICAL GROUP, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-987-3906
Mailing Address - Street 1:20 GRAND ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-987-3906
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:20 GRAND ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-1035
Practice Address - Country:US
Practice Address - Phone:845-987-3906
Practice Address - Fax:845-987-5979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCG4866OtherRAILROAD MEDICARE
PA1022201690002Medicaid
NY03313839Medicaid
NJ0538477Medicaid
NJ146545Medicare PIN