Healthcare Provider Details

I. General information

NPI: 1316540636
Provider Name (Legal Business Name): CONWAY ANESTHESIA SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 MAIN ST
CONWAY SC
29526-3568
US

IV. Provider business mailing address

1405 MAIN ST
CONWAY SC
29526-3568
US

V. Phone/Fax

Practice location:
  • Phone: 843-488-2898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES M PROCTOR
Title or Position: DIRECTOR
Credential: MD
Phone: 843-488-1895