Basic Information
| Provider Information | |||||||||
| NPI: | 1558928614 | ||||||||
| 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: | 3800 FABER PLACE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294058532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437974647 | ||||||||
| FaxNumber: | 8437450969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2019 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | MAYNOR-HARDY | ||||||||
| AuthorizedOfficialFirstName: | SARA ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8432258320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIBERTY DOCTORS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GP6738 | 05 | SC | MEDICAID |