Provider Demographics
NPI:1215043617
Name:CONWAY, MALCOLM L
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:L
Last Name:CONWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 WYOMING AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-1366
Mailing Address - Country:US
Mailing Address - Phone:570-287-7070
Mailing Address - Fax:570-287-5575
Practice Address - Street 1:1150 WYOMING AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:WYOMING
Practice Address - State:PA
Practice Address - Zip Code:18644-1366
Practice Address - Country:US
Practice Address - Phone:570-287-7070
Practice Address - Fax:570-287-5575
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002774L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACO124470KLJMedicare ID - Type Unspecified