MEDICARE: KYLE LIBBEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207QA0000X	Adolescent Medicine (Family Medicine) Physician	90431	GA

General Provider Information

NPI Number	:	1033620943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE LIBBEY MD

Provider Business Mailing Address
First Line	:	PO BOX 530062
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30353-0062
Country	:	US
Telephone Number	:	843-695-6071
Fax Number	:	843-569-5881

Provider Business Practice Location Address
First Line	:	9313 MEDICAL PLAZA DR STE 202
Second Line	:
City	:	N CHARLESTON
State	:	SC
Zip	:	29406-9176
Country	:	US
Telephone Number	:	843-572-1200
Fax Number	:	843-553-0424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2017
Last Update Date	:	09/08/2022

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Directions to “ KYLE LIBBEY MD” Practice Location

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