Healthcare Provider Details

I. General information

NPI: 1497060719
Provider Name (Legal Business Name): COLONIAL FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 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: 803-774-5400
Mailing address:
  • Phone: 803-773-5227
  • Fax: 803-774-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3006640
License Number StateSC

VIII. Authorized Official

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