Provider Demographics
NPI:1851389605
Name:CONWAY REGIONAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:CONWAY REGIONAL MEDICAL CENTER, INC.
Other - Org Name:MAYFLOWER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-450-2112
Mailing Address - Street 1:PO BOX 9662
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-9662
Mailing Address - Country:US
Mailing Address - Phone:501-852-1363
Mailing Address - Fax:501-852-1364
Practice Address - Street 1:606 HIGHWAY 365
Practice Address - Street 2:
Practice Address - City:MAYFLOWER
Practice Address - State:AR
Practice Address - Zip Code:72106-9595
Practice Address - Country:US
Practice Address - Phone:501-470-7413
Practice Address - Fax:501-470-7415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONWAY REGIONAL MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-06
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127018002Medicaid
AR127018002Medicaid
AR128442729Medicaid
AR127018002Medicaid