Provider Demographics
NPI:1376574038
Name:CANAVAN, AMY LANGHAM (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LANGHAM
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTENTION PATIENT ACCOUNTING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:124 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9260
Practice Address - Country:US
Practice Address - Phone:843-234-8788
Practice Address - Fax:843-234-8787
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86335208M00000X, 208000000X, 208M00000X, 208000000X
VA0101245788208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC863355Medicaid
TN3884479Medicaid
AL009910801Medicaid
TN4106436OtherBCBS OF TENNESSEE
GA220902644DMedicaid