Provider Demographics
NPI:1689928103
Name:CONWAY HOSPITAL COMMUNITY SERVICES
Entity Type:Organization
Organization Name:CONWAY HOSPITAL COMMUNITY SERVICES
Other - Org Name:CPG CENTER FOR WOUND HEALING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-347-7111
Mailing Address - Street 1:PO BOX 2180
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-2180
Mailing Address - Country:US
Mailing Address - Phone:843-234-5139
Mailing Address - Fax:843-234-6822
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-347-8347
Practice Address - Fax:843-234-6977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7844OtherMEDICARE PTAN
SCDC2203OtherRAILROAD MEDICARE GROUP
SCGP4505Medicaid