NPIMap

Organization Active NPI

Conway Regional Medical Center, Inc

Doing business as Conway Regional Medical Clinic-Russellville

  • Family Medicine Physician
  • Russellville, AR
National Provider Identifier
1245729359
Registry record updated Nov 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CONWAY REGIONAL MEDICAL CENTER, INC
Doing business as
Conway Regional Medical Clinic-Russellville
Practice address
108 Skyline Dr
Russellville, AR 72801-3362
Phone
(479) 968-7170
Fax
(479) 968-7607
NPI assigned
May 3, 2018
Last updated
Nov 9, 2023By the provider in NPPES
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
Family Medicine Physician 207Q00000X AR Primary

Addresses

Primary practice location

108 Skyline Dr
Russellville, AR 72801-3362

Mailing address

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

Other names 1

  • Conway Regional Medical Clinic-Russellville Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040605000199 AR Part B Supplier - Clinic/Group Practice 3173428414 Receives reassigned benefits from 50 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Conway, AR; Vilonia, AR; Russellville, AR; Pottsville, AR; Mayflower, AR; Greenbrier, AR; Clinton, AR
O20071201000077 AR Part A Provider - Hospital 3173428414 5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Conway, AR; Vilonia, AR; Russellville, AR; Greenbrier, AR; Mayflower, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1245729359. Details of each certification follow.

Hospital certification: CCN 040029

Legal name
CONWAY REGIONAL MEDICAL CENTER INC
Doing business as
CONWAY REGIONAL MEDICAL CENTER INC
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Jun 25, 2021
Beds
150
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Sep 26, 1938 in AR
Enrollment address
2302 College Avenue
Conway, AR 72034-6297
Other Hospital Practice Location
Hospital subgroups
Acute care, Psychiatric unit

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs on the same Medicare enrollment 11

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

Care Compare: Hospital

Medicare Care Compare
Listed as
Conway Regional Medical Center, IncCCN 040029 · All quality measures
Overall star rating
2 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

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
04D0468970Conway Regional Medical Clinic -Russellville108 Skyline Drive, Russellville, AR 72801Certificate of waiverMay 15, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Allison Bramlett Individual W-2 Managing EmployeeDelegated Official Jan 1, 2024
Susan Gatto Individual Operational/Managerial ControlBoard Member Jan 1, 2022
Thaddeus Michael Stanton Individual Operational/Managerial ControlBoard Member Jan 1, 2024
William Pack Individual W-2 Managing EmployeeCfo Aug 29, 2022
Operational/Managerial ControlCfo Aug 29, 2022
Matthew Troup Individual Corporate OfficerPresident & Ceo Sep 14, 2015
Jeremy O Riddle Individual Operational/Managerial ControlBoard Member Jan 1, 2024
Thad R Hardin Individual Operational/Managerial ControlBoard Member Jan 1, 2017
Jeffrey Standridge Individual Operational/Managerial ControlBoard Member Jan 1, 2017
Tom Poe Individual Operational/Managerial ControlBoard Member Jan 1, 2013
Gena Ester Individual Operational/Managerial ControlBoard Member Jan 1, 2022
Andrew Cole Individual Operational/Managerial ControlBoard Member Jan 1, 2012
Wayne Cox Individual Operational/Managerial ControlBoard Member Jan 1, 2013
Bryan Bruich Individual Operational/Managerial ControlBoard Member Jan 1, 2022

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

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.

Affiliated clinicians 490

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 490

NPI Registry JSON

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

{
    "created_epoch": "1525305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699488000000",
    "number": "1245729359",
    "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",
            "fax_number": "501-852-1364"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "108 SKYLINE DR",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728013362",
            "telephone_number": "479-968-7170",
            "fax_number": "479-968-7607"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CONWAY REGIONAL MEDICAL CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-05-03",
        "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": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AR",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Conway Regional Medical Clinic-Russellville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Russellville, AR

Sources for this page

Verify at the official NPI Registry.