Basic Information
Provider Information | |||||||||
NPI: | 1467698076 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONWAY HOSPITAL COMMUNITY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CPG FAMILY MEDICINE AT SINGLETON RIDGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 SINGLETON RIDGE RD | ||||||||
Address2: | ATTENTION PATIENT ACCOUNTING | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295269142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432346946 | ||||||||
FaxNumber: | 8432348958 | ||||||||
Practice Location | |||||||||
Address1: | 124 PROFESSIONAL PARK DR | ||||||||
Address2: | SUITE A | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295269260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433479500 | ||||||||
FaxNumber: | 8433479595 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2009 | ||||||||
LastUpdateDate: | 03/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARR | ||||||||
AuthorizedOfficialFirstName: | BRET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8433478114 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2336 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | GP4505 | 05 | SC |   | MEDICAID |