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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	30704	SC
2	364SF0001X	Family Health Clinical Nurse Specialist	1804	SC
3	364SF0001X	Family Health Clinical Nurse Specialist	3438	SC
4	208000000X	Pediatrics Physician		SC
5	207Q00000X	Family Medicine Physician		SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SC6924A634	OTHER	SC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700162203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY DOCTORS LLC

Provider Business Mailing Address
First Line	:	8761 DORCHESTER RD STE 230
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29420-7322
Country	:	US
Telephone Number	:	843-412-1590
Fax Number	:	843-225-3549

Provider Business Practice Location Address
First Line	:	8761 DORCHESTER RD STE 230
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29420-7322
Country	:	US
Telephone Number	:	843-471-2273
Fax Number	:	843-377-8180

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. LISSA C LARA
Credential	:
Telephone Number	:	843-412-1590

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	06/02/2026

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Directions to “LIBERTY DOCTORS LLC ” Practice Location

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