Provider Demographics
NPI:1073555454
Name:STOUT, MARSHALL JAMES (MD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:JAMES
Last Name:STOUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22670
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2670
Mailing Address - Country:US
Mailing Address - Phone:800-749-2940
Mailing Address - Fax:706-660-1454
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-2000
Practice Address - Fax:706-660-1454
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07363207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014778Medicaid
MS0119630Medicaid
MSC02387Medicare PIN
MS0119630Medicaid
MS930264846Medicare PIN