Provider Demographics
NPI:1104996073
Name:CONAWAY, MICHAEL BRENT (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRENT
Last Name:CONAWAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 TELETECH DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041
Mailing Address - Country:US
Mailing Address - Phone:304-843-3379
Mailing Address - Fax:304-221-3013
Practice Address - Street 1:100 TELETECH DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041
Practice Address - Country:US
Practice Address - Phone:304-843-3379
Practice Address - Fax:304-221-3013
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810008493Medicaid
OH2675154Medicaid
P00476589OtherRAILROAD MEDICARE
4179342Medicare PIN