NPIMap

Organization Active NPI

Conway Childrens Clinic PA Corp

  • Pediatrics Physician
  • Conway, AR
National Provider Identifier
1033170261
Registry record updated Feb 7, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
CONWAY CHILDRENS CLINIC PA CORP
Practice address
2505 College Ave
Conway, AR 72034
Phone
(501) 327-6000
Fax
(501) 450-7559
NPI assigned
Mar 29, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 7, 2011

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

Authorized official

Name
Mr. Michael A Connaughton, MD
Title
President
Phone
(501) 327-6000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary

Addresses

Primary practice location

2505 College Ave
Conway, AR 72034

Mailing address

2505 College Ave
Conway, AR 72034
Phone (501) 327-6000

Other identifiers 2

IdentifierTypeStateIssuer
57800OtherARBLUE CROSS
115903002MedicaidAR

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
This NPI is an additional NPI on the enrollment
Practice locations: Greenbrier, 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
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
04D0466258Conway Childrens Clinic2505 College Ave, Conway, AR 72034Provider-performed microscopyAug 31, 2026

National Provider Directory

National Provider Directory

Locations

2505 College Ave
Conway, AR 72034
Phone (501) 327-6000

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 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1143590400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1297036800000",
    "number": "1033170261",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2505 COLLEGE AVE",
            "city": "CONWAY",
            "state": "AR",
            "postal_code": "72034",
            "telephone_number": "501-327-6000",
            "fax_number": "501-450-7559"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2505 COLLEGE AVE",
            "city": "CONWAY",
            "state": "AR",
            "postal_code": "72034",
            "telephone_number": "501-327-6000",
            "fax_number": "501-450-7559"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CONWAY CHILDRENS CLINIC PA CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-29",
        "last_updated": "2011-02-07",
        "status": "A",
        "authorized_official_last_name": "CONNAUGHTON",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "501-327-6000",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "57800",
            "state": "AR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "115903002",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Conway, AR

Sources for this page

Verify at the official NPI Registry.