=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578559787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONWAY REGIONAL SURGERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 ADA AVE SUITE 100
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72034-4985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-730-0754
-----------------------------------------------------
Fax | 501-730-0718
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 ADA AVE SUITE 100
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72034-4985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-730-0754
-----------------------------------------------------
Fax | 501-730-0718
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | NANCY BURNETT
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 501-730-0754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 041036
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------