Provider Demographics
NPI:1821210121
Name:CHARLESTON ADULTS AND GERIATRICS
Entity Type:Organization
Organization Name:CHARLESTON ADULTS AND GERIATRICS
Other - Org Name:CHARLESTON ADULTS AND GRIATRICS
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:MAYNO-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 1:2175 ASHLEY PHOSPHATE RD
Practice Address - Street 2:SUITE D
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4181
Practice Address - Country:US
Practice Address - Phone:843-764-0770
Practice Address - Fax:843-863-0402
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY DOCTORS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
SC13680207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6738Medicaid
SCGP4032Medicaid
SCP00175892OtherRAILROAD MEDICARE PIN
SCGP6738Medicaid
SCDC5483Medicare ID - Type UnspecifiedRAILROAD GROUP
SCGP4032Medicaid
SCD90643Medicare UPIN