Basic Information
| Provider Information | |||||||||
| NPI: | 1548573322 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONWAY HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CPG INTERNAL MEDICINE MYRTLE TRACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | ATTENTION PATIENT ACCOUNTING | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432346946 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8004 MYRTLE TRACE DR | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432348939 | ||||||||
| FaxNumber: | 8432348959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2010 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARTIOLI | ||||||||
| AuthorizedOfficialFirstName: | MARY ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8432346946 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP4505 | 05 | SC | MEDICAID |