Healthcare Provider Details

I. General information

NPI: 1124462882
Provider Name (Legal Business Name): PATRICK W. CONWAY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BILL; CONWAY D.O.

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-5000
  • Fax:
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberTP766
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101021346
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: