Provider Demographics
NPI:1235198045
Name:CONWAY OB-GYN CLINIC PA
Entity Type:Organization
Organization Name:CONWAY OB-GYN CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:FAGALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-327-6547
Mailing Address - Street 1:2180 ADA AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6135
Mailing Address - Country:US
Mailing Address - Phone:501-327-6547
Mailing Address - Fax:501-327-9715
Practice Address - Street 1:2180 ADA AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6135
Practice Address - Country:US
Practice Address - Phone:501-327-6547
Practice Address - Fax:501-327-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115352002Medicaid
57638Medicare ID - Type Unspecified