Provider Demographics
NPI:1720869068
Name:LYERLY BAPTIST INC
Entity Type:Organization
Organization Name:LYERLY BAPTIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, MEDICAL DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:GORAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-202-7300
Mailing Address - Street 1:PO BOX 746647
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6647
Mailing Address - Country:US
Mailing Address - Phone:904-388-6518
Mailing Address - Fax:904-384-1005
Practice Address - Street 1:14546 OLD SAINT AUGUSTINE RD STE 409
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5473
Practice Address - Country:US
Practice Address - Phone:904-388-6518
Practice Address - Fax:904-384-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty