Provider Demographics
NPI:1760083562
Name:LIBERTY DOCTORS LLC
Entity Type:Organization
Organization Name:LIBERTY DOCTORS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
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 1:9133 TIMBER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9075
Mailing Address - Country:US
Mailing Address - Phone:843-779-6444
Mailing Address - Fax:843-779-6438
Practice Address - Street 1:9133 TIMBER ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9075
Practice Address - Country:US
Practice Address - Phone:843-779-6444
Practice Address - Fax:843-779-6438
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY DOCTORS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA634OtherMEDICARE PART B
SCGP6738Medicaid