Healthcare Provider Details

I. General information

NPI: 1003478462
Provider Name (Legal Business Name): CONWAY REGIONAL MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WESTERN AVE STE 305A
CONWAY AR
72034-4982
US

IV. Provider business mailing address

PO BOX 9662
CONWAY AR
72033-9662
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-6145
  • Fax: 501-504-6642
Mailing address:
  • Phone: 501-852-1363
  • Fax: 501-852-1364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM PACK
Title or Position: CFO
Credential:
Phone: 501-450-2112