Basic Information
| Provider Information | |||||||||
| NPI: | 1104820133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONVILLE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | HOWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 CARTHAGE ST | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273304162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197746023 | ||||||||
| FaxNumber: | 9197766359 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 CARTHAGE ST | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273304162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197746023 | ||||||||
| FaxNumber: | 9197766359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20316 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 412013354 | 01 | NC | RR MEDICARE | OTHER | 0138851 | 01 | NC | UNITED HEALTHCARE | OTHER | 270326 | 01 | NC | MAMSI | OTHER | 133545617 | 01 | NC | TRICARE | OTHER | 8955856 | 05 | NC | MEDICAID | 3913 | 01 | NC | PARTNERS | OTHER | 27772 | 01 | NC | MEDCOST | OTHER | 55856 | 01 | NC | BCBS | OTHER |