Organization
COLONIAL FAMILY PRACTICE, LLC
Active
Other names
Colonial Family Practice Bultman
Organization subpart
No
Provider details
NPI number
Authorized official
STEPHANIE K DISHER (CREDENTIALING SPECIALIST)
(803) 773-5227
Entity
Organization
Contact information
Practice address
698 BULTMAN DR, SUITE A, SUMTER, SC 29150
(803) 773-5227
(803) 753-9312
Mailing address
325 BROAD ST, SUITE 100, SUMTER, SC 29150-4167
(803) 773-5227
(803) 753-9312
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
17676
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
42D2126583
CLIA
SC
05
—
GP3564
—
SC
Enumeration date
01/31/2014
Last updated
12/15/2020
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