Healthcare Provider Details

I. General information

NPI: 1124090774
Provider Name (Legal Business Name): WESLEY S CONWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 MARION ST
COLUMBIA SC
29220-2910
US

IV. Provider business mailing address

555 E. CHEVES ST. ATTN: RADIOLOGY DEPARTMENT/MRMC
FLORENCE SC
29506-2617
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-5513
  • Fax: 803-296-3076
Mailing address:
  • Phone: 843-777-2879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number28797
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: