Basic Information
| Provider Information | |||||||||
| NPI: | 1104996073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONAWAY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BRENT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1212 GARFIELD AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261013247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048656778 | ||||||||
| FaxNumber: | 3048657400 | ||||||||
| Practice Location | |||||||||
| Address1: | 841 COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | WELLSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260701528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047370437 | ||||||||
| FaxNumber: | 3047370581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 790 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2675154 | 05 | OH | MEDICAID | 3810008493 | 05 | WV | MEDICAID | P00476589 | 01 | RAILROAD MEDICARE | OTHER |