Provider Demographics
NPI:1750385639
Name:CONWAY, PETER MITCHEL (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:MITCHEL
Last Name:CONWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-253-1035
Mailing Address - Fax:502-253-1037
Practice Address - Street 1:3900 KRESGE WAY
Practice Address - Street 2:SUITE 31
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4660
Practice Address - Country:US
Practice Address - Phone:502-894-0664
Practice Address - Fax:502-238-2835
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19967208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100359670Medicaid
KY64199672Medicaid
KY0232002Medicare PIN
IN100359670Medicaid
C74397Medicare UPIN