Healthcare Provider Details

I. General information

NPI: 1518986637
Provider Name (Legal Business Name): CONWAY PEDIATRICS,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 BELL ST
CONWAY SC
29526-4113
US

IV. Provider business mailing address

907 BELL ST
CONWAY SC
29526-4113
US

V. Phone/Fax

Practice location:
  • Phone: 843-248-2727
  • Fax: 843-248-5107
Mailing address:
  • Phone: 843-248-2727
  • Fax: 843-248-5107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number4548
License Number StateSC

VIII. Authorized Official

Name: DR. THOMAS PETRUSICK
Title or Position: DOCTOR
Credential: MD
Phone: 843-248-2727