MEDICARE: LIBERTY DOCTORS, LLC

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	207Q00000X	Family Medicine Physician		SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689051369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY DOCTORS, LLC

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

Provider Business Practice Location Address
First Line	:	418 FOLLY RD STE A
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-2625
Country	:	US
Telephone Number	:	843-795-5362
Fax Number	:	843-795-1921

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CHELSEY DEVER
Credential	:
Telephone Number	:	843-225-8320

Provider Enumeration Date	:	05/01/2015
Last Update Date	:	12/15/2025

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