Provider Demographics
NPI:1083663892
Name:LIBERTY FAMILY CARE
Entity Type:Organization
Organization Name:LIBERTY FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:MERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-843-5605
Mailing Address - Street 1:300 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:SC
Mailing Address - Zip Code:29657-1012
Mailing Address - Country:US
Mailing Address - Phone:864-843-5605
Mailing Address - Fax:864-843-0996
Practice Address - Street 1:300 W FRONT ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1012
Practice Address - Country:US
Practice Address - Phone:864-843-5605
Practice Address - Fax:864-843-0996
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAPTIST EASLEY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-09
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5257OtherMEDICAID GRP-BAPTIST EASLEY -LIBERTY FAMILY CARE EFFECTIVE 10-1-2009
SCGP2653OtherMEDICAID-PHBE-LFC INEFFECTIVE 9-30-2009
SC1801028543OtherNPI-BAPTIST EASLEY-LIBERTY FAMILY CARE EFFECTIVE 10-1-2009
SC6578Medicare PIN
SCGP5257OtherMEDICAID GRP-BAPTIST EASLEY -LIBERTY FAMILY CARE EFFECTIVE 10-1-2009