Provider Demographics
NPI:1972194199
Name:AMELIA ISLAND SURGERY CENTER LLC
Entity Type:Organization
Organization Name:AMELIA ISLAND SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:STACKHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-261-5741
Mailing Address - Street 1:1005 W INDIANTOWN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-6834
Mailing Address - Country:US
Mailing Address - Phone:561-630-6277
Mailing Address - Fax:561-630-6062
Practice Address - Street 1:2416 LYNNDALE RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-5201
Practice Address - Country:US
Practice Address - Phone:904-261-5741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-30
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2416OtherNONE