Provider Demographics
NPI:1902229214
Name:COLONIAL FAMILY PRACTICE & AMBULATORY CARE CENTER
Entity Type:Organization
Organization Name:COLONIAL FAMILY PRACTICE & AMBULATORY CARE CENTER
Other - Org Name:COLONIAL FAMILY PRACTICE COLUMBIA
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:803-753-9121
Practice Address - Street 1:4700 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206
Practice Address - Country:US
Practice Address - Phone:803-773-5227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLONIAL FAMILY PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-23
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28747207P00000X
SC25518207Q00000X
SC17676261QE0800X
261QH0100X, 363A00000X, 363L00000X, 363LF0000X
SC07-6916 GLENN GOUDY261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3564Medicaid
SCPTAN 7477Medicare PIN