Provider Demographics
NPI:1245729359
Name:CONWAY REGIONAL MEDICAL CENTER, INC
Entity type:Organization
Organization Name:CONWAY REGIONAL MEDICAL CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:108 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3362
Practice Address - Country:US
Practice Address - Phone:479-968-7170
Practice Address - Fax:479-968-7607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-03
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty