=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982437745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYERLY BAPTIST INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2024
-----------------------------------------------------
Last Update Date | 10/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1747 BAPTIST CLAY DR STE 200
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-8505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-516-1950
-----------------------------------------------------
Fax | 904-376-3062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 746647
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-6647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-202-2092
-----------------------------------------------------
Fax | 904-376-4075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | TYRONE MCCLOUD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-202-5367
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------