Healthcare Provider Details

I. General information

NPI: 1720869068
Provider Name (Legal Business Name): LYERLY BAPTIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14546 OLD SAINT AUGUSTINE RD STE 409
JACKSONVILLE FL
32258-5473
US

IV. Provider business mailing address

PO BOX 746647
ATLANTA GA
30374-6647
US

V. Phone/Fax

Practice location:
  • Phone: 904-388-6518
  • Fax: 904-384-1005
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD J. GORAK
Title or Position: VP, MEDICAL DIRECTOR OF OPERATIONS
Credential: MD
Phone: 904-202-7300