Basic Information
| Provider Information | |||||||||
| NPI: | 1952482952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONWAY INTERNISTS, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8002 MYRTLE TRACE DR. | ||||||||
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| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433477227 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8002 MYRTLE TRACE DR. | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433477227 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 8433477227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4459 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PA7901 | 05 | SC | MEDICAID | 1323 | 01 | SC | MEDICARE PTAN | OTHER |