Healthcare Provider Details

I. General information

NPI: 1417967092
Provider Name (Legal Business Name): LIBERTY DOCTORS LLC D/B/A FAMILY FIRST MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 ASHLEY CROSSING DR STE 150
CHARLESTON SC
29414-5702
US

IV. Provider business mailing address

PO BOX 13955
CHARLESTON SC
29422-3955
US

V. Phone/Fax

Practice location:
  • Phone: 843-766-1936
  • Fax: 843-766-1206
Mailing address:
  • Phone: 843-225-8320
  • Fax: 843-225-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24446
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21948
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6385
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5942
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22266
License Number StateSC

VIII. Authorized Official

Name: MRS. ELIZABETH MAYNOR-HARDY
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 843-225-8320