Provider Demographics
NPI:1447212204
Name:CONWAY OUTPATIENT SURGERY CENTER
Entity Type:Organization
Organization Name:CONWAY OUTPATIENT SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KARI
Authorized Official - Middle Name:H
Authorized Official - Last Name:LANDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-336-9629
Mailing Address - Street 1:PO BOX 1755
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033
Mailing Address - Country:US
Mailing Address - Phone:501-336-9629
Mailing Address - Fax:501-336-0018
Practice Address - Street 1:1377 HWY 64 WEST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032
Practice Address - Country:US
Practice Address - Phone:501-336-9629
Practice Address - Fax:501-336-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11034261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
O41034Medicare UPIN
11034Medicare ID - Type Unspecified