Provider Demographics
NPI:1376854406
Name:LIBERTY DOCTORS, LLC
Entity Type:Organization
Organization Name:LIBERTY DOCTORS, LLC
Other - Org Name:MOBILE MEDICAL CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ELIZABETH
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:843-225-8304
Mailing Address - Fax:843-225-3549
Practice Address - Street 1:8761 DORCHESTER RD
Practice Address - Street 2:SUITE 230
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7322
Practice Address - Country:US
Practice Address - Phone:843-471-2273
Practice Address - Fax:843-377-8180
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY DOCTORS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-23
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
SC27193207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6738Medicaid
SCGP6738Medicaid
SCA634Medicare UPIN