Basic Information
| Provider Information | |||||||||
| NPI: | 1033244793 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONWAY HOSPITAL COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50760 | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295790013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432345169 | ||||||||
| FaxNumber: | 8432346822 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433478114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | CLAYTON | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8433478114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 20362 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207Y00000X | 21986 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207Q00000X | 828 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP4505 | 05 | SC | MEDICAID |