Healthcare Provider Details

I. General information

NPI: 1760083562
Provider Name (Legal Business Name): LIBERTY DOCTORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9133 TIMBER ST
NORTH CHARLESTON SC
29406-9075
US

IV. Provider business mailing address

9133 TIMBER ST
NORTH CHARLESTON SC
29406-9075
US

V. Phone/Fax

Practice location:
  • Phone: 843-779-6444
  • Fax: 843-779-6438
Mailing address:
  • Phone: 843-779-6444
  • Fax: 843-779-6438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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