Provider Demographics
| NPI: | 1518074640 |
|---|---|
| Name: | COLONIAL FAMILY PRACTICE, LLC |
| Entity Type: | Organization |
| Organization Name: | COLONIAL FAMILY PRACTICE, LLC |
| Other - Org Name: | COLONIAL FAMILY PRACTICE |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | MD/CEO |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | CLAYTON |
| Authorized Official - Middle Name: | R |
| Authorized Official - Last Name: | LOWDER |
| Authorized Official - Suffix: | III |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 803-773-5227 |
| Mailing Address - Street 1: | 325 BROAD ST. STE 100 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | SUMTER |
| Mailing Address - State: | SC |
| Mailing Address - Zip Code: | 29150-4167 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 803-773-5227 |
| Mailing Address - Fax: | 803-746-7445 |
| Practice Address - Street 1: | 325 BROAD ST. STE 100 |
| Practice Address - Street 2: | |
| Practice Address - City: | SUMTER |
| Practice Address - State: | SC |
| Practice Address - Zip Code: | 29150-4167 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 803-773-5227 |
| Practice Address - Fax: | 803-746-7445 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-08-24 |
| Last Update Date: | 2019-10-15 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| SC | 5499 | 101Y00000X |
| SC | 356 | 207L00000X |
| 207LP2900X, 208D00000X, 208VP0000X, 332B00000X, 363A00000X, 363L00000X, 363LF0000X | ||
| SC | 1013679 | 207Q00000X |
| SC | 25247 | 207QS1201X |
| SC | 445 | 207R00000X |
| SC | 29909 | 208000000X |
| SC | 33281 | 2084N0400X |
| SC | 17676 | 208600000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
| No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
| No | 207QS1201X | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| SC | GP3564 | Medicaid | |
| SC | GP6122 | Medicaid | |
| SC | GP6388 | Medicaid | |
| SC | GP6363 | Medicaid | |
| SC | GP6464 | Medicaid | |
| SC | GP6276 | Medicaid | |
| SC | GP6186 | Medicaid | |
| SC | GP6457 | Medicaid | |
| SC | GP6457 | Medicaid |
