Provider Demographics
NPI:1336184837
Name:MELTON R STUCKEY
Entity Type:Organization
Organization Name:MELTON R STUCKEY
Other - Org Name:COLUMBIA FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:STUCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-254-2222
Mailing Address - Street 1:PO BOX 11098
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29211-1098
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1333 TAYLOR ST
Practice Address - Street 2:SUITE 5-E
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2923
Practice Address - Country:US
Practice Address - Phone:803-256-1518
Practice Address - Fax:803-256-9719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0186Medicaid
SC3665Medicare PIN