Provider Demographics
NPI:1679863633
Name:STOUT, MICHAEL TYLER (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYLER
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 1:1151 N STATE ST STE 311
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-969-1171
Mailing Address - Fax:
Practice Address - Street 1:1151 N STATE ST STE 311
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2407
Practice Address - Country:US
Practice Address - Phone:601-969-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN67910207L00000X
MS23817207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology