Healthcare Provider Details

I. General information

NPI: 1164833026
Provider Name (Legal Business Name): COLONIAL FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 W WESMARK BLVD
SUMTER SC
29150
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: 803-753-9121
Mailing address:
  • Phone: 803-773-5227
  • Fax: 803-753-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25247
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33281
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number00-8178
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number25247
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2006
License Number StateSC
# 8
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number33821
License Number StateSC

VIII. Authorized Official

Name: DAVID GLENN WHALEY
Title or Position: PARTNER
Credential: MD
Phone: 803-773-5227