Healthcare Provider Details

I. General information

NPI: 1831302512
Provider Name (Legal Business Name): SURGICAL ASSOCIATES OF CONWAY PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WESTERN AVE SUITE 203
CONWAY AR
72034-4967
US

IV. Provider business mailing address

525 WESTERN AVE SUITE 203
CONWAY AR
72034-4967
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-4828
  • Fax: 501-327-6899
Mailing address:
  • Phone: 501-327-4828
  • Fax: 501-327-6899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMC1888
License Number StateAR

VIII. Authorized Official

Name: DR. THADDEUS MICHAEL STANTON
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 501-327-4828