Provider Demographics
NPI:1477517209
Name:CONWAY ADULT MEDICINE
Entity Type:Organization
Organization Name:CONWAY ADULT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-248-7568
Mailing Address - Street 1:903 BELL ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4113
Mailing Address - Country:US
Mailing Address - Phone:843-248-7568
Mailing Address - Fax:843-248-3906
Practice Address - Street 1:903 BELL ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4113
Practice Address - Country:US
Practice Address - Phone:843-248-7568
Practice Address - Fax:843-248-3906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12032207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA8688Medicaid
SC2569Medicare PIN
SCC60272Medicare UPIN