Bon Secours Richmond Health System: save time by filling out your physician profile online.

Bon Secours Health System - Physician Profile Only Form

The purpose of this form is to add the Physician Profile for Active Directory Services (ADS) and ConnectCare. The Physician Academy ID is a number assigned to the physician for dictation purposes. The Academy ID can be found by calling CCVS at 804/643-2287. This form must be filled out completely prior to processing by Information Services.

The NPI number can be found at the National Plan and Provider Enumeration System or click the following link, https://nppes.cms.hhs.gov/NPPES/Welcome.do

NPI Number *

First Name *

Middle Initial *

Last Name *

Select Specialty *

Academy ID *

License Number*

Group Name *

Phone Number *

Fax Number *

Address *

City *

State *

Zip *

Provider Email Address *

Comments *

Requestor Name *

If you do not have an email account, please use the default email address- no_email_account@bshsi.org.-in the field below.

Requestor Email Address *

* required fields

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