Healthcare Provider Details

I. General information

NPI: 1184169799
Provider Name (Legal Business Name): LIBERTY DOCTORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110A SPRINGHALL DR
GOOSE CREEK SC
29445-5335
US

IV. Provider business mailing address

PO BOX 13955
CHARLESTON SC
29422-3955
US

V. Phone/Fax

Practice location:
  • Phone: 843-973-8503
  • Fax: 843-990-5068
Mailing address:
  • Phone: 843-225-8320
  • Fax: 843-225-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number016192
License Number StateSC

VIII. Authorized Official

Name: CHELSEY DEVER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 843-225-8320