Provider Demographics
NPI:1417967092
Name:LIBERTY DOCTORS LLC D/B/A FAMILY FIRST MEDICAL CARE
Entity Type:Organization
Organization Name:LIBERTY DOCTORS LLC D/B/A FAMILY FIRST MEDICAL CARE
Other - Org Name:HEALTH CARE CONSULTANTS OF CHARLESTON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name: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 150
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5702
Practice Address - Country:US
Practice Address - Phone:843-766-1936
Practice Address - Fax:843-766-1206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22266207Q00000X
SC21948207Q00000X
SC24446207Q00000X
SC6385207Q00000X
SC5942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB1015OtherMEDCOST
SC247743969OtherBCBS
SCGP3158Medicaid
SC194667Medicaid
SC280508389OtherBCBS
SC257064675OtherBCBS
SC400560049OtherBCBS
SC247253076OtherBCBS
SCG33574Medicare UPIN
SC194667Medicaid
SCGP3158Medicaid
SC247743969OtherBCBS
SC257064675OtherBCBS
SCH59795Medicare UPIN