Provider Demographics
NPI:1285066233
Name:COLONIAL FAMILY PRACTICE NE
Entity type:Organization
Organization Name:COLONIAL FAMILY PRACTICE NE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-773-5227
Mailing Address - Street 1:325 BROAD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4167
Mailing Address - Country:US
Mailing Address - Phone:803-773-5227
Mailing Address - Fax:803-753-9121
Practice Address - Street 1:11 GATEWAY CORNERS PARK
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8902
Practice Address - Country:US
Practice Address - Phone:803-773-5227
Practice Address - Fax:803-462-0375
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLONIAL FAMILY PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-01
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
SC25856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPTAN7477Medicare Oscar/Certification