Provider Demographics
NPI:1457733057
Name:CONWAY PAIN CLINIC, PLLC
Entity Type:Organization
Organization Name:CONWAY PAIN CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEVIN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-327-6665
Mailing Address - Street 1:2425 PRINCE ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3746
Mailing Address - Country:US
Mailing Address - Phone:501-358-6560
Mailing Address - Fax:877-653-3202
Practice Address - Street 1:2425 PRINCE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3746
Practice Address - Country:US
Practice Address - Phone:501-358-6560
Practice Address - Fax:877-653-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC3115207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty