1255358263 NPI number — CONWAY UROLOGY, PA

Table of content: (NPI 1255358263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255358263 NPI number — CONWAY UROLOGY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONWAY UROLOGY, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255358263
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
495 HOGAN LANE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-327-5850
Provider Business Mailing Address Fax Number:
501-327-4910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 HOGAN LANE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-327-5850
Provider Business Practice Location Address Fax Number:
501-327-4910
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHIRLEY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
CRAIG
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
501-327-5850

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MC-1601 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: N-7212 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 113501-001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 159254002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com