Provider Demographics
NPI:1700162203
Name:LIBERTY DOCTORS LLC
Entity Type:Organization
Organization Name:LIBERTY DOCTORS LLC
Other - Org Name:MOBILE MEDICAL CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-412-1590
Mailing Address - Street 1:8761 DORCHESTER RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-7321
Mailing Address - Country:US
Mailing Address - Phone:843-412-1590
Mailing Address - Fax:843-225-3549
Practice Address - Street 1:8761 DORCHESTER RD STE 230
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7322
Practice Address - Country:US
Practice Address - Phone:843-471-2273
Practice Address - Fax:843-377-8180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X, 208000000X
SC30704207ZP0102X
SC3438364SF0001X
SC1804364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG50785Medicaid
SCSC6924A634OtherMEDICARE PTAN
SCGP6738Medicaid