Healthcare Provider Details

I. General information

NPI: 1497178131
Provider Name (Legal Business Name): COLONIAL FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date: 11/03/2020
Reactivation Date: 12/15/2020

III. Provider practice location address

698 BULTMAN DR SUITE A
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: 803-753-9312
Mailing address:
  • Phone: 803-773-5227
  • Fax: 803-753-9312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17676
License Number StateSC

VIII. Authorized Official

Name: STEPHANIE K DISHER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 803-773-5227