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General NPI Number Information
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NPI Number | 1720869068
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Entity Type | Organization
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Legal Business Name | LYERLY BAPTIST INC
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Dates
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Enumeration Date | 10/12/2023
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 14546 OLD SAINT AUGUSTINE RD STE 409
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City | JACKSONVILLE
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State | FL
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Zip | 32258-5473
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Country | US
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Telephone | 904-388-6518
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Fax | 904-384-1005
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Provider Business Mailing Address
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Address Line | PO BOX 746647
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City | ATLANTA
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State | GA
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Zip | 30374-6647
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Country | US
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Telephone | 904-202-2092
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Fax | 904-376-4075
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Authorized Official
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Title or Position | VP, MEDICAL DIRECTOR OF OPERATIONS
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Name | EDWARD J. GORAK
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Credential | MD
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Telephone | 904-202-7300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number |
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License Number State |
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