Provider Demographics
NPI:1033620943
Name:LIBBEY, KYLE (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:LIBBEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5881
Practice Address - Street 1:9313 MEDICAL PLAZA DR STE 202
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9176
Practice Address - Country:US
Practice Address - Phone:843-572-1200
Practice Address - Fax:843-553-0424
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA90431207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program