Provider Demographics
NPI:1689006652
Name:COLONIAL FAMILY PRACTICE - MANNING
Entity Type:Organization
Organization Name:COLONIAL FAMILY PRACTICE - MANNING
Other - Org Name:COLONIAL FAMILY PRACTICE MANNING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:KNIGHT
Authorized Official - Last Name:DISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-773-5227
Mailing Address - Street 1:325 BROAD ST
Mailing Address - Street 2:SUITE 100
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:803-753-9121
Practice Address - Street 1:1036 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2827
Practice Address - Country:US
Practice Address - Phone:803-773-5227
Practice Address - Fax:803-433-5221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLONIAL FAMILY PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-01
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13915207Q00000X
207Q00000X, 363A00000X, 363AM0700X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPTAN7477Medicare Oscar/Certification