Provider Demographics
NPI:1881639862
Name:LIBERTY DOCTORS, LLC
Entity Type:Organization
Organization Name:LIBERTY DOCTORS, LLC
Other - Org Name:FAMILY FIRST MEDICAL CARE
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 1:1483 TOBIAS GADSON BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-8702
Practice Address - Country:US
Practice Address - Phone:843-766-1936
Practice Address - Fax:843-766-1206
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY DOCTORS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC0310207Q00000X
SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3558Medicaid
SCGP6738Medicaid
SC7261Medicare PIN
SCA634Medicare UPIN
SCD27209Medicare UPIN