Basic Information
| Provider Information | |||||||||
| NPI: | 1033844253 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY DOCTORS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13955 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294223955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432258320 | ||||||||
| FaxNumber: | 8432253549 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 JUNGLE RD | ||||||||
| Address2: | |||||||||
| City: | EDISTO ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294383005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432258320 | ||||||||
| FaxNumber: | 8432253549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2022 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PINA | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8432258320 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIBERTY DOCTORS, LLC | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.