Healthcare Provider Details

I. General information

NPI: 1174656367
Provider Name (Legal Business Name): E.A. CONWAY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 JACKSON ST
MONROE LA
71202-6400
US

IV. Provider business mailing address

4864 JACKSON ST
MONROE LA
71202-6400
US

V. Phone/Fax

Practice location:
  • Phone: 318-330-7000
  • Fax: 318-675-5666
Mailing address:
  • Phone: 318-330-7000
  • Fax: 318-675-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number129
License Number StateLA

VIII. Authorized Official

Name: MELANIE H SOTAK
Title or Position: DIRECTOR OF MANAGED CARE
Credential: MHSA
Phone: 318-675-7737