Individual
MARK J STOUT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
725 AMERICAN AVE, WAUKESHA, WI 53188-5031
(608) 263-1530
Mailing address
725 AMERICAN AVE, WAUKESHA, WI 53188-5031
Taxonomy
Speciality
Code
Description
License number
State
204F00000X
Transplant Surgery Physician
Primary
62383
WI
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
01069517A
IN
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
036080105
IL
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
62383
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001005823
ANTHEM PROVIDER NUMBER FOR TIN 35-2030653
IN
01
—
01605360
BCBS PROVIDER ID
IL
05
—
036080105
—
IL
05
—
201019900
—
IN
01
—
780000280
RAILROAD MEDICARE
IL
01
—
P01027332
RAILROAD MEDICARE
IN
Enumeration date
09/19/2005
Last updated
05/03/2021
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