Provider Demographics
NPI:1154340552
Name:CONWAY REGIONAL MEDICAL CENTER INC
Entity type:Organization
Organization Name:CONWAY REGIONAL MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-450-2112
Mailing Address - Street 1:2843 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3637
Mailing Address - Country:US
Mailing Address - Phone:501-329-9377
Mailing Address - Fax:501-329-0724
Practice Address - Street 1:2843 PRINCE ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3637
Practice Address - Country:US
Practice Address - Phone:501-329-9377
Practice Address - Fax:501-329-0724
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONWAY REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-18
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4068251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102221514Medicaid
5000028OtherUNITED HEALTHCARE
047083OtherCOMMERCIAL INSURANCES
17083OtherBLUE CROSS
AR102221514Medicaid
AR102221514Medicaid