Healthcare Provider Details

I. General information

NPI: 1508928656
Provider Name (Legal Business Name): LIBERTY DOCTORS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8761 DORCHESTER RD STE 100
NORTH CHARLESTON SC
29420-7320
US

IV. Provider business mailing address

PO BOX 13955
CHARLESTON SC
29422-3955
US

V. Phone/Fax

Practice location:
  • Phone: 843-767-3323
  • Fax: 843-767-4252
Mailing address:
  • Phone: 843-225-8304
  • Fax: 843-225-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number17172
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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