Healthcare Provider Details

I. General information

NPI: 1457733057
Provider Name (Legal Business Name): CONWAY PAIN CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 PRINCE ST SUITE 3
CONWAY AR
72034-3746
US

IV. Provider business mailing address

2425 PRINCE ST SUITE 3
CONWAY AR
72034-3746
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-6560
  • Fax: 877-653-3202
Mailing address:
  • Phone: 501-358-6560
  • Fax: 877-653-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMC3115
License Number StateAR

VIII. Authorized Official

Name: JEVIN ALLEN SMITH
Title or Position: ORGANIZER/ PRESIDENT
Credential: M.D.
Phone: 501-327-6665