Basic Information
| Provider Information | |||||||||
| NPI: | 1629570387 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONWAY HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CMC PRIMARY CARE POSTAL WAY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SINGLETON RIDGE ROAD | ||||||||
| Address2: | ATTENTION PNS CREDENTIALING | ||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432346946 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4022 POSTAL WAY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295793537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432360000 | ||||||||
| FaxNumber: | 8432366191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | BARR | ||||||||
| AuthorizedOfficialFirstName: | BRET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8433478114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP8567 | 05 | SC | MEDICAID |