Basic Information
| Provider Information | |||||||||
| NPI: | 1700162203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY DOCTORS LLC | ||||||||
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| OtherOrganizationName: | MOBILE MEDICAL CONSULTANTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8761 DORCHESTER RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294207321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434121590 | ||||||||
| FaxNumber: | 8432253549 | ||||||||
| Practice Location | |||||||||
| Address1: | 8761 DORCHESTER RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294207322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434712273 | ||||||||
| FaxNumber: | 8433778180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | LARA | ||||||||
| AuthorizedOfficialFirstName: | LISSA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8434121590 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | 1804 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 207ZP0102X | 30704 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 208000000X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 364SF0001X | 3438 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 207Q00000X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | G50785 | 05 | SC | MEDICAID | SC6924A634 | 01 | SC | MEDICARE PTAN | OTHER | GP6738 | 05 | SC | MEDICAID |