1497178131 NPI number — COLONIAL FAMILY PRACTICE, LLC

Table of content: (NPI 1497178131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497178131 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:
Provider Other Organization Name Type Code:
6
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:
1497178131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/03/2020
NPI Reactivation Date:
12/15/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 BROAD ST
Provider Second Line Business Mailing Address:
SUITE 100
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:
803-753-9312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
698 BULTMAN DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150
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:
803-753-9312
Provider Enumeration Date:
01/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DISHER
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
803-773-5227

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  17676 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP3564 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42D2126583 . This is a "CLIA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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