Healthcare Provider Details

I. General information

NPI: 1972194199
Provider Name (Legal Business Name): AMELIA ISLAND SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2021
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 LYNNDALE RD
FERNANDINA BEACH FL
32034-5201
US

IV. Provider business mailing address

1005 W INDIANTOWN RD STE 101
JUPITER FL
33458-6834
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-5741
  • Fax:
Mailing address:
  • Phone: 561-630-6277
  • Fax: 561-630-6062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. J. RUSSELL STACKHOUSE
Title or Position: MANAGER
Credential: MD
Phone: 904-261-5741