Healthcare Provider Details

I. General information

NPI: 1427892728
Provider Name (Legal Business Name): CONWAY HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 62ND AVE N STE A
MYRTLE BEACH SC
29572-7202
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD ATTENTION PNS CREDENTIALING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-839-0957
  • Fax: 843-839-0758
Mailing address:
  • Phone: 843-234-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierPG2250
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: MARY ELLEN ARTIOLI
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 843-234-6946