NPIMap

Organization Active NPI

Conway Childrens Clinic PA Corp

Doing business as Greenbrier Childrens Clinic

  • Rural Health Clinic/Center
  • Greenbrier, AR
National Provider Identifier
1003189606
Registry record updated Feb 14, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
CONWAY CHILDRENS CLINIC PA CORP
Doing business as
Greenbrier Childrens Clinic
Practice address
10 Lois Lane
Greenbrier, AR 72058
Phone
(501) 679-6796
NPI assigned
Feb 14, 2012
Last updated
Feb 14, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 14, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Michael Connaughton, MD
Title
Owner/MD
Phone
(501) 327-6000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

10 Lois Lane
Greenbrier, AR 72058

Mailing address

10 Lois Lane
Greenbrier, AR 72058
Phone (501) 679-6796

Other names 1

  • Greenbrier Childrens Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110226000128 AR Part A Provider - Rural Health Clinic 2466633227 1 other NPI on this enrollment
Practice locations: Greenbrier, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003189606. Details of each certification follow.

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
CorporationProprietary
Incorporated
Jan 1, 1987 in AR
Enrollment address
10 Lois Lane
Greenbrier, AR 72058-8506

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D2197980Conway Childrens Clinic Greenbrier10 Lois Lane, Greenbrier, AR 72058Certificate of waiverOct 28, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Christopher Killingsworth Individual 5% Or Greater Direct Ownership Interest Aug 1, 2013 33.3%
Dawn Sutherland Individual 5% Or Greater Direct Ownership Interest Jan 1, 1994 33.3%
Kelly Staley Individual 5% Or Greater Direct Ownership Interest Jan 1, 2001 33.3%
W-2 Managing Employee Jan 1, 2011 33.3%

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1329177600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1329177600000",
    "number": "1003189606",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10 LOIS LANE",
            "city": "GREENBRIER",
            "state": "AR",
            "postal_code": "72058",
            "telephone_number": "501-679-6796"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10 LOIS LANE",
            "city": "GREENBRIER",
            "state": "AR",
            "postal_code": "72058",
            "telephone_number": "501-679-6796"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CONWAY CHILDRENS CLINIC PA CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-02-14",
        "last_updated": "2012-02-14",
        "status": "A",
        "authorized_official_last_name": "CONNAUGHTON",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER/MD",
        "authorized_official_telephone_number": "501-327-6000",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Greenbrier Childrens Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Greenbrier, AR

Sources for this page

Verify at the official NPI Registry.