Healthcare Provider Details

I. General information

NPI: 1104443100
Provider Name (Legal Business Name): CHARLES JONATHAN LYERLY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 N BROAD ST
PHILADELPHIA PA
19107-1531
US

IV. Provider business mailing address

235 N BROAD ST
PHILADELPHIA PA
19107-1531
US

V. Phone/Fax

Practice location:
  • Phone: 215-568-3510
  • Fax:
Mailing address:
  • Phone: 215-568-3510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC007120
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: