Conway Childrens Clinic PA Corp
Organization Active NPI Rural Health Clinic/Center · Greenbrier, AR
NPI 1003189606 · NPPES record last updated Feb 14, 2012
Key facts
- NPI
- 1003189606
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- CONWAY CHILDRENS CLINIC PA CORP
- Practice address
- 10 Lois Lane
Greenbrier, AR 72058 - Phone
- (501) 679-6796
- NPI assigned
- Feb 14, 2012
- Organization subpart
- No
Authorized official
- Name
- Michael Connaughton, MD
- Title
- Owner/MD
- Phone
- (501) 327-6000
Other NPIs on the same Medicare enrollment 1
Practitioners 7
-
Kirsten Leigh Kravitz, MSN CPNP
-
Lisa J. Martin, APN
-
Allie Sparks, APRN
-
Hannah Voegele, FNP-BC
-
Katelin D Whiddon, A.P.R.N.
-
Deborah S Wingfield, APN
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 04D2197980 | Conway Childrens Clinic Greenbrier | Certificate of waiver | Oct 28, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AR
Rural health clinic certification: CCN 043872
- Legal name
- CONWAY CHILDRENS CLINIC PA CORP
- Doing business as
- GREENBRIER CHILDRENS CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Sep 9, 2011
- Last certification
- Aug 23, 2017
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Incorporated
- Jan 1, 1987 in AR
- Enrollment address
- 10 Lois Lane
Greenbrier, AR 72058-8506
All disclosed owners & managing parties 3
| Name | Role | Since | Share |
|---|---|---|---|
| Christopher Killingsworth |
5% Or Greater Direct Ownership Interest | Aug 1, 2013 | 33.3% |
| Dawn Sutherland |
5% Or Greater Direct Ownership Interest | Jan 1, 1994 | 33.3% |
| Kelly Staley |
5% Or Greater Direct Ownership Interest | Jan 1, 2001 | 33.3% |
| W-2 Managing Employee | Jan 1, 2011 | 33.3% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20110226000128 | AR | Part a Provider - Rural Health Clinic | 2466633227 |
1 other NPI on this enrollment Practice locations: Greenbrier, AR |
National Provider Directory
Locations
10 Lois Ln
Greenbrier, AR 72058
Phone (501) 679-6796
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
10 Lois Lane
Greenbrier, AR 72058
Mailing address
10 Lois Lane
Greenbrier, AR 72058
Phone (501) 679-6796
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 043872 | Other | CMS# |
Other names
- Greenbrier Childrens Clinic
Other providers in Greenbrier, AR
- Lakin Coffman
- Stephanie Karol Coleman
- Community Medical Clinic
- Chelsea Condra
- Katelyn Coney
- Conway Regional Medical Center Inc
- Conway Regional Medical Center Inc
- Chasity Cooley
- Grayson Carolann Craig
- Carmen M. Crawford
All providers in Greenbrier, AR · Rural Health Clinic/Center in Arkansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 14, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.