NPIMap

Organization Active NPI

Conway Regional Medical Center, Inc

  • General Practice Dentistry
  • Conway, AR
National Provider Identifier
1043864093
Registry record updated Nov 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
CONWAY REGIONAL MEDICAL CENTER, INC
Practice address
830 N Creek Dr
Conway, AR 72032-4711
Phone
(501) 932-0559
Fax
(501) 205-1983
NPI assigned
Jul 29, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 9, 2023

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

Authorized official

Name
William Pack
Title
Cfo
Phone
(501) 450-2112

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X Primary

Addresses

Primary practice location

830 N Creek Dr
Conway, AR 72032-4711

Mailing address

PO Box 9662
Conway, AR 72033-9662
Phone (501) 852-1363

Other names 1

  • Conway Regional Interfaith Dental Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191004000080 AR Part B Supplier - Hospital Department(S) 3173428414 Receives reassigned benefits from 1 practitioner
Practice locations: Conway, AR

National Provider Directory

National Provider Directory
Tax ID family
Center Ridge Family Med15 organizations share this tax ID, including this one

Other organizations with this tax ID 14

Organizations that report the same tax identification number in the National Provider Directory.

View all 14

Ownership & related parties

All facility ownership & control disclosures 8

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Conway Regional Rehabilitation Hospital LLCConway, AR, CCN 043033 Hospital 5% Or Greater Direct Ownership Interest (69.6%) Apr 6, 2004
Dardanelle Regional Medical CenterDardanelle, AR, CCN 04Z302 Hospital 5% Or Greater Indirect Ownership Interest (100%) Jan 1, 2022
Dardanelle Regional Medical CenterDardanelle, AR, CCN 04M302 Hospital 5% Or Greater Indirect Ownership Interest (100%) Jan 1, 2022
Dardanelle Regional Medical CenterDardanelle, AR, CCN 041302 Hospital 5% Or Greater Indirect Ownership Interest (100%) Jan 1, 2022
Conway Regional Medical Clinic - ViloniaVilonia, AR, CCN 048536 Rural health clinic Operational/Managerial Control (100%) Dec 11, 2014
Greenbrier Family MedicineGreenbrier, AR, CCN 048534 Rural health clinic 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Oct 25, 2004
Oct 25, 2004
Mayflower Medical ClinicMayflower, AR, CCN 048537 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Oct 25, 2004
Clinton Medical ClinicClinton, AR, CCN 048563 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Oct 25, 2004

Practitioners & affiliated clinicians

Practitioners 4

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": "1564358400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699488000000",
    "number": "1043864093",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 9662",
            "city": "CONWAY",
            "state": "AR",
            "postal_code": "720339662",
            "telephone_number": "501-852-1363"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "830 N CREEK DR",
            "city": "CONWAY",
            "state": "AR",
            "postal_code": "720324711",
            "telephone_number": "501-932-0559",
            "fax_number": "501-205-1983"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CONWAY REGIONAL MEDICAL CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-07-29",
        "last_updated": "2023-11-09",
        "certification_date": "2023-11-09",
        "status": "A",
        "authorized_official_last_name": "PACK",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "501-450-2112"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Conway Regional Interfaith Dental Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Conway Regional Interfaith Dental Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Conway, AR

Sources for this page

Verify at the official NPI Registry.