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NPI Code Detail

MEDICARE: LIBERTY DOCTORS LLC

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
1207Q00000XFamily Medicine Physician

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1A634OTHERSCMEDICARE PART B

Other Identifiers

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

General Provider Information

NPI Number : 1760083562
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIBERTY DOCTORS LLC
Provider Business Mailing Address
First Line : 9133 TIMBER ST
Second Line :
City : NORTH CHARLESTON
State : SC
Zip : 29406-9075
Country : US
Telephone Number : 843-779-6444
Fax Number : 843-779-6438
Provider Business Practice Location Address
First Line : 9133 TIMBER ST
Second Line :
City : NORTH CHARLESTON
State : SC
Zip : 29406-9075
Country : US
Telephone Number : 843-779-6444
Fax Number : 843-779-6438
Authorized Official
Title or Position : CREDENTIALING MANAGER
Name : MRS. SARA ELIZABETH MAYNOR-HARDY
Credential :
Telephone Number : 843-225-8320
Provider Enumeration Date : 11/06/2020
Last Update Date : 11/06/2020

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1922336536 — SARAH C BRUNSON RN, IBCLC, RLC
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1336326750 — DR. BRIAN CHRISTOPHER BRIDGES M.D.
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171 ASHLEY AVE
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Directions to “LIBERTY DOCTORS LLC ” Practice Location

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