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General NPI Number Information
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NPI Number | 1972194199
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Entity Type | Organization
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Legal Business Name | AMELIA ISLAND SURGERY CENTER LLC
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Dates
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Enumeration Date | 01/30/2021
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Last Update Date | 09/29/2021
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Provider Practice Location Address
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Address Line | 2416 LYNNDALE RD
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City | FERNANDINA BEACH
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State | FL
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Zip | 32034-5201
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Country | US
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Telephone | 904-261-5741
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Fax |
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Provider Business Mailing Address
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Address Line | 1005 W INDIANTOWN RD STE 101
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City | JUPITER
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State | FL
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Zip | 33458-6834
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Country | US
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Telephone | 561-630-6277
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Fax | 561-630-6062
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Authorized Official
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Title or Position | MANAGER
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Name | DR. J. RUSSELL STACKHOUSE
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Credential | MD
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Telephone | 904-261-5741
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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