Provider Demographics
NPI:1174656367
Name:E.A. CONWAY MEDICAL CENTER
Entity Type:Organization
Organization Name:E.A. CONWAY MEDICAL CENTER
Other - Org Name:E.A. CONWAY MEDICAL CENTER CRNAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SOTAK
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:318-675-7737
Mailing Address - Street 1:4864 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-6400
Mailing Address - Country:US
Mailing Address - Phone:318-330-7000
Mailing Address - Fax:318-675-5666
Practice Address - Street 1:4864 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6400
Practice Address - Country:US
Practice Address - Phone:318-330-7000
Practice Address - Fax:318-675-5666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA129367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1799882Medicaid
LA1799882Medicaid