Basic Information
Provider Information | |||||||||
NPI: | 1881639862 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIBERTY DOCTORS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILY FIRST MEDICAL CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 13955 | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294223955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432258304 | ||||||||
FaxNumber: | 8432253549 | ||||||||
Practice Location | |||||||||
Address1: | 1483 TOBIAS GADSON BLVD | ||||||||
Address2: | SUITE 206 | ||||||||
City: | CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294078702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437661936 | ||||||||
FaxNumber: | 8437661206 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2006 | ||||||||
LastUpdateDate: | 10/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAYNOR-HARDY | ||||||||
AuthorizedOfficialFirstName: | SARA | ||||||||
AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 8432258320 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LIBERTY DOCTORS, LLC | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | SC0310 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X |   | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | GP3558 | 05 | SC |   | MEDICAID | GP6738 | 05 | SC |   | MEDICAID |