Provider Demographics
NPI:1578645933
Name:CONWAY, KIRK (PT)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:CONWAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-0492
Mailing Address - Country:US
Mailing Address - Phone:410-535-9850
Mailing Address - Fax:
Practice Address - Street 1:110 MAIN STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4022
Practice Address - Country:US
Practice Address - Phone:410-535-9850
Practice Address - Fax:410-535-9851
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17145225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD134866ZA9ZMedicare PIN