Healthcare Provider Details

I. General information

NPI: 1033620943
Provider Name (Legal Business Name): KYLE LIBBEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9313 MEDICAL PLAZA DR STE 202
N CHARLESTON SC
29406-9176
US

IV. Provider business mailing address

PO BOX 530062
ATLANTA GA
30353-0062
US

V. Phone/Fax

Practice location:
  • Phone: 843-572-1200
  • Fax: 843-553-0424
Mailing address:
  • Phone: 843-695-6071
  • Fax: 843-569-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number90431
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: