Provider Demographics
NPI:1124090774
Name:CONWELL, WESLEY S (MD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:S
Last Name:CONWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E. CHEVES ST.
Mailing Address - Street 2:ATTN: RADIOLOGY DEPARTMENT/MRMC
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2617
Mailing Address - Country:US
Mailing Address - Phone:843-777-2879
Mailing Address - Fax:
Practice Address - Street 1:1519 MARION ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29220-2910
Practice Address - Country:US
Practice Address - Phone:803-296-5513
Practice Address - Fax:803-296-3076
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC287972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC28797OtherMEDICAL LICENSE
SC287978Medicaid
SCI286381530Medicare PIN
SCI28638Medicare UPIN