MEDICARE: LIBERTY DOCTORS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	20234	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4225947	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144299470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY DOCTORS LLC

Provider Business Mailing Address
First Line	:	110 EXECUTIVE PKWY
Second Line	:
City	:	MONCKS CORNER
State	:	SC
Zip	:	29461-3930
Country	:	US
Telephone Number	:	843-408-4171
Fax Number	:	888-318-5567

Provider Business Practice Location Address
First Line	:	110 EXECUTIVE PKWY
Second Line	:
City	:	MONCKS CORNER
State	:	SC
Zip	:	29461-3930
Country	:	US
Telephone Number	:	843-899-9099
Fax Number	:	888-318-5567

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CHELSEY DEVER
Credential	:
Telephone Number	:	843-225-8320

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	12/15/2025

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