Organization
COLONIAL FAMILY PRACTICE, LLC
Active
Parent organization
COLONIAL FAMILY PRACTICE, LLC
Other names
Colonial Pediatrics
Organization subpart
Yes
Provider details
NPI number
Legal business name
COLONIAL FAMILY PRACTICE, LLC
Authorized official
STEPHANIE KNIGHT DISHER (CREDENTIALING MANAGER)
(803) 773-5227
Entity
Organization
Contact information
Practice address
742 W LIBERTY ST, SUMTER, SC 29150-4746
(803) 773-5227
(803) 774-5400
Mailing address
325 BROAD ST, SUITE 100, SUMTER, SC 29150-4167
(803) 773-5227
(803) 774-5400
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
5499
SC
208000000X
Pediatrics Physician
Primary
3004950
SC
363LF0000X
Family Nurse Practitioner
—
—
363LP0200X
Pediatric Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GP3564
—
SC
Enumeration date
08/12/2008
Last updated
03/22/2021
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