Provider Demographics
NPI:1033170261
Name:CONWAY CHILDRENS CLINIC PA CORP
Entity Type:Organization
Organization Name:CONWAY CHILDRENS CLINIC PA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONNAUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-327-6000
Mailing Address - Street 1:2505 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-327-6000
Mailing Address - Fax:501-450-7559
Practice Address - Street 1:2505 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-327-6000
Practice Address - Fax:501-450-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57800OtherBLUE CROSS
AR115903002Medicaid