NPIMap

Organization Active NPI

Colonial Family Practice & Ambulatory Care Center

Doing business as Colonial Family Practice Columbia

  • Family Medicine Physician
  • Columbia, SC
National Provider Identifier
1902229214
Registry record updated Mar 22, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
25518 Issued in SC
Legal business name
COLONIAL FAMILY PRACTICE & AMBULATORY CARE CENTER
Doing business as
Colonial Family Practice Columbia
Practice address
4700 Forest Dr
Columbia, SC 29206
Phone
(803) 773-5227
NPI assigned
Jan 23, 2014
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 8

Specialty (taxonomy)CodeLicenseStatePrimary
Endoscopy Clinic/Center 261QE0800X 17676 SC
Health Service Clinic/Center 261QH0100X
Magnetic Resonance Imaging (MRI) Clinic/Center 261QM1200X 07-6916 GLENN GOUDY SC
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Family Nurse Practitioner 363LF0000X
Emergency Medicine Physician 207P00000X 28747 SC
Family Medicine Physician 207Q00000X 25518 SC Primary

Addresses

Primary practice location

4700 Forest Dr
Columbia, SC 29206

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
GP3564MedicaidSC

Other names 1

  • Colonial Family Practice Columbia 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
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.

Locations

674 W Liberty St
Sumter, SC 29150
Phone 80377352276010

Practitioners & affiliated clinicians

Practitioners 68

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 68

NPI Registry JSON

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

{
    "created_epoch": "1390435200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1616371200000",
    "number": "1902229214",
    "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": "803-753-9121"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4700 FOREST DR",
            "city": "COLUMBIA",
            "state": "SC",
            "postal_code": "29206",
            "telephone_number": "803-773-5227"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COLONIAL FAMILY PRACTICE & AMBULATORY CARE CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COLONIAL FAMILY PRACTICE, LLC",
        "enumeration_date": "2014-01-23",
        "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": "261QE0800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Endoscopy",
            "state": "SC",
            "license": "17676",
            "primary": false
        },
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Magnetic Resonance Imaging (MRI)",
            "state": "SC",
            "license": "07-6916 GLENN GOUDY",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "SC",
            "license": "28747",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SC",
            "license": "25518",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP3564",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Colonial Family Practice Columbia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Columbia, 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.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.