Basic Information
| Provider Information | |||||||||
| NPI: | 1518268317 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONWAY HOSPITAL COMMUNITY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CPG COASTAL METABOLIC & BARIATRIC SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2180 | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295282180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432345139 | ||||||||
| FaxNumber: | 8432346822 | ||||||||
| Practice Location | |||||||||
| Address1: | 2376 CYPRESS CIR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433473900 | ||||||||
| FaxNumber: | 8433473930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2010 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARR | ||||||||
| AuthorizedOfficialFirstName: | BRET | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8433477111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207RB0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP4505 | 05 | SC | MEDICAID |