Provider Demographics
NPI:1477583169
Name:COLBURN, JENNIFER SOMMERVILLE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SOMMERVILLE
Last Name:COLBURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:SOMMERVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:1686 SKYLYN DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1079
Practice Address - Country:US
Practice Address - Phone:864-582-8135
Practice Address - Fax:864-573-9757
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863102OtherBCBS
SC272234Medicaid
SC576007863102OtherBCBS
SCAA22557951Medicare PIN