MEDICARE: AMELIA ISLAND SURGERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2416	OTHER	FL	NONE

General Provider Information

NPI Number	:	1972194199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMELIA ISLAND SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	1005 W INDIANTOWN RD STE 101
Second Line	:
City	:	JUPITER
State	:	FL
Zip	:	33458-6834
Country	:	US
Telephone Number	:	561-630-6277
Fax Number	:	561-630-6062

Provider Business Practice Location Address
First Line	:	2416 LYNNDALE RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-5201
Country	:	US
Telephone Number	:	904-261-5741
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. J. RUSSELL STACKHOUSE
Credential	:	MD
Telephone Number	:	904-261-5741

Provider Enumeration Date	:	01/30/2021
Last Update Date	:	09/29/2021

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Directions to “AMELIA ISLAND SURGERY CENTER LLC ” Practice Location

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