Provider Demographics
NPI:1194380162
Name:LIBERTY DOCTORS, LLC
Entity Type:Organization
Organization Name:LIBERTY DOCTORS, LLC
Other - Org Name:LAURA LEE KINNEY MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNOR-HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-225-8320
Mailing Address - Street 1:PO BOX 13955
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29422-3955
Mailing Address - Country:US
Mailing Address - Phone:843-225-8320
Mailing Address - Fax:843-225-3549
Practice Address - Street 1:2270 ASHLEY CROSSING DR STE 165
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5865
Practice Address - Country:US
Practice Address - Phone:843-936-4455
Practice Address - Fax:843-268-2670
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY DOCTORS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-06
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6738Medicaid
SC194667Medicaid
SCA634OtherMEDICARE PTAN