NPIMap

Organization Active NPI

Colonial Family Practice, LLC

Doing business as Colonial Family Practice Bultman

  • Family Medicine Physician
  • Sumter, SC
National Provider Identifier
1497178131
Registry record updated Dec 15, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
17676 Issued in SC
Legal business name
COLONIAL FAMILY PRACTICE, LLC
Doing business as
Colonial Family Practice Bultman
Practice address
698 Bultman Dr
Suite a
Sumter, SC 29150
Phone
(803) 773-5227
Fax
(803) 753-9312
NPI assigned
Jan 31, 2014
Reactivated
Dec 15, 2020
Last updated
Dec 15, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 15, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Stephanie K Disher
Title
Credentialing Specialist
Phone
(803) 773-5227

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 17676 SC Primary

Addresses

Primary practice location

698 Bultman Dr
Suite a
Sumter, SC 29150

Mailing address

325 Broad St
Suite 100
Sumter, SC 29150-4167
Phone (803) 773-5227

Other identifiers 2

IdentifierTypeStateIssuer
42D2126583OtherSCCLIA
GP3564MedicaidSC

Other names 1

  • Colonial Family Practice Bultman Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040727000107 SC Part B Supplier - Clinic/Group Practice 9931017118 Receives reassigned benefits from 88 practitioners
23 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Sumter, SC; Camden, SC; Manning, SC; Columbia, SC

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

National Provider Directory

National Provider Directory

Locations

674 W Liberty St
Sumter, SC 29150
Phone 80377352276010

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1391126400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1607990400000",
    "number": "1497178131",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "325 BROAD ST",
            "address_2": "SUITE 100",
            "city": "SUMTER",
            "state": "SC",
            "postal_code": "291504167",
            "telephone_number": "803-773-5227",
            "fax_number": "803-753-9312"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "698 BULTMAN DR",
            "address_2": "SUITE A",
            "city": "SUMTER",
            "state": "SC",
            "postal_code": "29150",
            "telephone_number": "803-773-5227",
            "fax_number": "803-753-9312"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COLONIAL FAMILY PRACTICE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-01-31",
        "last_updated": "2020-12-15",
        "certification_date": "2020-12-15",
        "deactivation_date": "2020-11-03",
        "reactivation_date": "2020-12-15",
        "status": "A",
        "authorized_official_last_name": "DISHER",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "803-773-5227"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SC",
            "license": "17676",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA",
            "identifier": "42D2126583",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP3564",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Colonial Family Practice Bultman",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sumter, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.