Organization
COLONIAL FAMILY PRACTICE & AMBULATORY CARE CENTER
Active
Parent organization
COLONIAL FAMILY PRACTICE, LLC
Other names
Colonial Family Practice Columbia
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
4700 FOREST DR, COLUMBIA, SC 29206
(803) 773-5227
Mailing address
325 BROAD ST, SUITE 100, SUMTER, SC 29150-4167
(803) 773-5227
(803) 753-9121
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
28747
SC
207Q00000X
Family Medicine Physician
Primary
25518
SC
261QE0800X
Endoscopy Clinic/Center
17676
SC
261QH0100X
Health Service Clinic/Center
—
—
261QM1200X
Magnetic Resonance Imaging (MRI) Clinic/Center
07-6916 GLENN GOUDY
SC
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GP3564
—
SC
Enumeration date
01/23/2014
Last updated
03/22/2021
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