Provider Demographics
NPI:1265473698
Name:AMELIA ISLAND PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:AMELIA ISLAND PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-430-0271
Mailing Address - Street 1:5472 FIRST COAST HWY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:AMELIA ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32034-5488
Mailing Address - Country:US
Mailing Address - Phone:904-430-0271
Mailing Address - Fax:904-430-0290
Practice Address - Street 1:5472 FIRST COAST HWY
Practice Address - Street 2:SUITE 3
Practice Address - City:AMELIA ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32034-5488
Practice Address - Country:US
Practice Address - Phone:904-430-0271
Practice Address - Fax:904-430-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty