Provider Demographics
NPI:1184169799
Name:LIBERTY DOCTORS LLC
Entity type:Organization
Organization Name:LIBERTY DOCTORS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
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:843-225-8320
Mailing Address - Fax:843-225-3549
Practice Address - Street 1:110A SPRINGHALL DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5335
Practice Address - Country:US
Practice Address - Phone:843-973-8503
Practice Address - Fax:843-990-5068
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY DOCTORS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-05
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC016192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6738Medicaid
SC161924Medicaid
SCA634OtherMEDICARE PIN