Provider Demographics
NPI:1003009069
Name:LIBERTY MEDICAL SPECIALTIES, INC.
Entity Type:Organization
Organization Name:LIBERTY MEDICAL SPECIALTIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-642-2250
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0339
Mailing Address - Country:US
Mailing Address - Phone:910-642-2250
Mailing Address - Fax:910-642-0109
Practice Address - Street 1:1768 HIGHWAY 501
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-9750
Practice Address - Country:US
Practice Address - Phone:843-448-8315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY MEDICAL SPECIALTIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-23
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0476TOtherBCBS
NC7701229Medicaid
SCDE3292Medicaid
NC0586150010Medicare NSC