1881639862 NPI number — LIBERTY DOCTORS, LLC

Table of content: (NPI 1881639862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881639862 NPI number — LIBERTY DOCTORS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY DOCTORS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY FIRST MEDICAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881639862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13955
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29422-3955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-225-8304
Provider Business Mailing Address Fax Number:
843-225-3549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1483 TOBIAS GADSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29407-8702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-766-1936
Provider Business Practice Location Address Fax Number:
843-766-1206
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAYNOR-HARDY
Authorized Official First Name:
SARA
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
843-225-8320

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  SC0310 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP3558 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP6738 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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