NPIMap

Organization Active NPI

Colonial Family Practice, LLC

Doing business as Colonial Pediatrics

  • Pediatrics Physician
  • Sumter, SC
National Provider Identifier
1851547640
Registry record updated Mar 22, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
License
3004950 Issued in SC
Legal business name
COLONIAL FAMILY PRACTICE, LLC
Doing business as
Colonial Pediatrics
Practice address
742 W Liberty St
Sumter, SC 29150-4746
Phone
(803) 773-5227
Fax
(803) 774-5400
NPI assigned
Aug 12, 2008
Last updated
Mar 22, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
COLONIAL FAMILY PRACTICE, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 22, 2021

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

Authorized official

Name
Stephanie Knight Disher
Title
Credentialing Manager
Phone
(803) 773-5227

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X
Pediatric Nurse Practitioner 363LP0200X
Professional Counselor 101YP2500X 5499 SC
Pediatrics Physician 208000000X 3004950 SC Primary

Addresses

Primary practice location

742 W Liberty St
Sumter, SC 29150-4746

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
GP3564MedicaidSC

Other names 1

  • Colonial Pediatrics 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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
42D1089270Colonial Pediatrics742 West Liberty, Sumter, SC 29150Certificate of waiverNov 7, 2027

National Provider Directory

National Provider Directory
Tax ID family
Colonial Family Practice LLC8 organizations share this tax ID, including this one
Part of
Colonial Family Practice LLC

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 44

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.

View all 44

NPI Registry JSON

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

{
    "created_epoch": "1218499200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1616371200000",
    "number": "1851547640",
    "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": "803-774-5400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "742 W LIBERTY ST",
            "city": "SUMTER",
            "state": "SC",
            "postal_code": "291504746",
            "telephone_number": "803-773-5227",
            "fax_number": "803-774-5400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COLONIAL FAMILY PRACTICE, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COLONIAL FAMILY PRACTICE, LLC",
        "enumeration_date": "2008-08-12",
        "last_updated": "2021-03-22",
        "certification_date": "2021-03-22",
        "status": "A",
        "authorized_official_last_name": "DISHER",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_middle_name": "KNIGHT",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "803-773-5227"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "SC",
            "license": "5499",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "SC",
            "license": "3004950",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP3564",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Colonial Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Colonial Pediatrics",
            "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 Mar 22, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.