1518074640 NPI number — COLONIAL FAMILY PRACTICE, LLC

Table of content: (NPI 1518074640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518074640 NPI number — COLONIAL FAMILY PRACTICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL FAMILY PRACTICE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COLONIAL FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518074640
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 BROAD ST. STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29150-4167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-773-5227
Provider Business Mailing Address Fax Number:
803-746-7445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 BROAD ST. STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-4167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-773-5227
Provider Business Practice Location Address Fax Number:
803-746-7445
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOWDER
Authorized Official First Name:
CLAYTON
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MD/CEO
Authorized Official Telephone Number:
803-773-5227

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  5499 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 356 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 1013679 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QS1201X , with the licence number: 25247 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 445 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 29909 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 33281 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 17676 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP3564 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP6122 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP6388 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP6363 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP6464 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP6276 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP6186 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP6457 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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