Provider Demographics
NPI:1851547640
Name:COLONIAL FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:COLONIAL FAMILY PRACTICE, LLC
Other - Org Name:COLONIAL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
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:803-774-5400
Practice Address - Street 1:742 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4746
Practice Address - Country:US
Practice Address - Phone:803-773-5227
Practice Address - Fax:803-774-5400
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLONIAL FAMILY PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-12
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5499101YP2500X
SC3004950208000000X
363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3564Medicaid
SC7477Medicare PIN