Provider Demographics
NPI:1003189606
Name:CONWAY CHILDRENS CLINIC PA CORP
Entity Type:Organization
Organization Name:CONWAY CHILDRENS CLINIC PA CORP
Other - Org Name:GREENBRIER CHILDRENS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNAUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-327-6000
Mailing Address - Street 1:10 LOIS LANE
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058
Mailing Address - Country:US
Mailing Address - Phone:501-679-6796
Mailing Address - Fax:
Practice Address - Street 1:10 LOIS LANE
Practice Address - Street 2:
Practice Address - City:GREENBRIER
Practice Address - State:AR
Practice Address - Zip Code:72058
Practice Address - Country:US
Practice Address - Phone:501-679-6796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
043872OtherCMS#