Healthcare Provider Details

I. General information

NPI: 1821313883
Provider Name (Legal Business Name): LYERLY BAPTIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14546 OLD SAINT AUGUSTINE RD SUITE 301
JACKSONVILLE FL
32258-5468
US

IV. Provider business mailing address

14546 OLD SAINT AUGUSTINE RD SUITE 301
JACKSONVILLE FL
32258-5468
US

V. Phone/Fax

Practice location:
  • Phone: 904-292-4049
  • Fax: 904-292-4805
Mailing address:
  • Phone: 904-292-4049
  • Fax: 904-292-4805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME81147
License Number StateFL

VIII. Authorized Official

Name: EARL B MALLY
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 904-376-4275