Healthcare Provider Details

I. General information

NPI: 1033170261
Provider Name (Legal Business Name): CONWAY CHILDRENS CLINIC PA CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 COLLEGE AVE
CONWAY AR
72034
US

IV. Provider business mailing address

2505 COLLEGE AVE
CONWAY AR
72034
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-6000
  • Fax: 501-450-7559
Mailing address:
  • Phone: 501-327-6000
  • Fax: 501-450-7559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL A CONNAUGHTON
Title or Position: PRESIDENT
Credential: MD
Phone: 501-327-6000