Provider Demographics
NPI:1265439632
Name:CONWAY ENDOSCOPY CENTER, INC.
Entity type:Organization
Organization Name:CONWAY ENDOSCOPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HEATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-764-1960
Mailing Address - Street 1:PO BOX 10780
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-0013
Mailing Address - Country:US
Mailing Address - Phone:501-764-1960
Mailing Address - Fax:501-513-0798
Practice Address - Street 1:455 HOGAN LN
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8201
Practice Address - Country:US
Practice Address - Phone:501-764-1960
Practice Address - Fax:501-513-0798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR3956261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145383128Medicaid
AR145383128Medicaid
AR11049Medicare ID - Type Unspecified