Basic Information
Provider Information | |||||||||
NPI: | 1043632805 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONWAY HOSPITAL COMMUNITY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CPG WOMEN'S HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 50760 | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295790013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432346827 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8004 MYRTLE TRACE DR | ||||||||
Address2: |   | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295268945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433477216 | ||||||||
FaxNumber: | 8433477218 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2014 | ||||||||
LastUpdateDate: | 01/15/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARR | ||||||||
AuthorizedOfficialFirstName: | BRETT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP FISCAL SERVICES | ||||||||
AuthorizedOfficialTelephone: | 8432345139 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.