Healthcare Provider Details

I. General information

NPI: 1902229214
Provider Name (Legal Business Name): COLONIAL FAMILY PRACTICE & AMBULATORY CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 FOREST DR
COLUMBIA SC
29206
US

IV. Provider business mailing address

325 BROAD ST SUITE 100
SUMTER SC
29150-4167
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-5227
  • Fax:
Mailing address:
  • Phone: 803-773-5227
  • Fax: 803-753-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number28747
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number17676
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number07-6916 GLENN GOUDY
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25518
License Number StateSC

VIII. Authorized Official

Name: STEPHANIE KNIGHT DISHER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 803-773-5227