Healthcare Provider Details

I. General information

NPI: 1669575809
Provider Name (Legal Business Name): JOHN A CONWAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 MARION RD SUITE ONE
WAREHAM MA
02571
US

IV. Provider business mailing address

53 MARION ROAD SUITE ONE
WAREHAM MA
02571
US

V. Phone/Fax

Practice location:
  • Phone: 508-295-8622
  • Fax: 508-295-4909
Mailing address:
  • Phone: 508-295-8622
  • Fax: 508-295-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number39782
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0420004648
License Number StateVT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2043696
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: