Basic Information
| Provider Information | |||||||||
| NPI: | 1245729359 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONWAY REGIONAL MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONWAY REGIONAL MEDICAL CLINIC-RUSSELLVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799687170 | ||||||||
| FaxNumber: | 4799687607 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799687170 | ||||||||
| FaxNumber: | 4799687607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2018 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | FINLEY | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5014502114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.