NPIMap

Organization Active NPI

Russell Stackhouse MD PA

Doing business as Coastal Vision Center

  • Ophthalmology Physician
  • Fernandina, FL
National Provider Identifier
1538655014
Registry record updated Dec 13, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
License
ME117902 Issued in FL
Legal business name
RUSSELL STACKHOUSE MD PA
Doing business as
Coastal Vision Center
Practice address
6 S 14TH St
Fernandina, FL 32034-3212
Phone
(904) 261-5741
Fax
(904) 261-7383
NPI assigned
Jul 8, 2018
Last updated
Dec 13, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 13, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Nichole Rene Barnett
Title
Practice Administrator
Phone
(904) 261-5741

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Ophthalmology Physician 207W00000X ME117902 FL Primary
Orthopaedic Foot and Ankle Surgery Physician 207XX0004X NU

Addresses

Primary practice location

6 S 14TH St
Fernandina, FL 32034-3212

Mailing address

6 S 14TH St
Fernandina, FL 32034-3212
Phone (904) 261-5741

Other identifiers 1

IdentifierTypeStateIssuer
070583OtherDATE OF BIRTH

Other names 1

  • Coastal Vision Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL, GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20181107000636 FL Part B Supplier - Clinic/Group Practice 9133473325 Receives reassigned benefits from 16 practitioners
Practice locations: Fernandina, FL
O20200122001607 GA Part B Supplier - Clinic/Group Practice 9133473325 Receives reassigned benefits from 5 practitioners
Practice locations: Saint Marys, GA; Waycross, GA

National Provider Directory

National Provider Directory

Locations

2416 Lynndale Rd
Fernandina Beach, FL 32034
Phone (904) 432-1521

2416 Lynndale Rd
Ste 201
Fernandina Beach, FL 32034
Phone 9042615741134

6 S 14th St
Fernandina Beach, FL 32034
Phone (904) 261-5741

31 S 6th St
Macclenny, FL 32063
Phone (904) 259-6259

2900 Saint Marys Rd
Saint Marys, GA 31558
Phone (904) 261-5741

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1531008000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1670889600000",
    "number": "1538655014",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6 S 14TH ST",
            "city": "FERNANDINA",
            "state": "FL",
            "postal_code": "320343212",
            "telephone_number": "904-261-5741",
            "fax_number": "904-261-7383"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6 S 14TH ST",
            "city": "FERNANDINA",
            "state": "FL",
            "postal_code": "320343212",
            "telephone_number": "904-261-5741",
            "fax_number": "904-261-7383"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RUSSELL STACKHOUSE MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-08",
        "last_updated": "2022-12-13",
        "certification_date": "2022-12-13",
        "status": "A",
        "authorized_official_last_name": "BARNETT",
        "authorized_official_first_name": "NICHOLE",
        "authorized_official_middle_name": "RENE",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "904-261-5741"
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "FL",
            "license": "ME117902",
            "primary": true
        },
        {
            "code": "207XX0004X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery, Foot and Ankle Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DATE OF BIRTH",
            "identifier": "070583",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Coastal Vision Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fernandina, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.