Provider Demographics
| NPI: | 1710961172 |
|---|---|
| Name: | STOUT, KERRICK LOUIS (MD) |
| Entity Type: | Individual |
| Prefix: | |
| First Name: | KERRICK |
| Middle Name: | LOUIS |
| 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 130 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | DILLINGHAM |
| Mailing Address - State: | AK |
| Mailing Address - Zip Code: | 99576-0130 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 907-842-9218 |
| Mailing Address - Fax: | 907-842-9500 |
| Practice Address - Street 1: | 6000 KANAKANAK RD |
| Practice Address - Street 2: | |
| Practice Address - City: | DILLINGHAM |
| Practice Address - State: | AK |
| Practice Address - Zip Code: | 99576 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 907-842-5201 |
| Practice Address - Fax: | 907-842-9250 |
| Is Sole Proprietor?: | No |
| Enumeration Date: | 2005-11-30 |
| Last Update Date: | 2015-03-11 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| AK | 4902 | 207Q00000X |
| KY | 34237 | 207Q00000X, 207P00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| AK | MD6411 | Medicaid | |
| G99087 | Medicare UPIN | ||
| 8EZ89U | Medicare ID - Type Unspecified | ||
| 8EZ92U | Medicare ID - Type Unspecified | ||
| 8EZ94U | Medicare ID - Type Unspecified | ||
| 8EZ80U | Medicare ID - Type Unspecified | ||
| 8EZ90U | Medicare ID - Type Unspecified | ||
| 8EZ78U | Medicare ID - Type Unspecified | ||
| 8EZ84U | Medicare ID - Type Unspecified | ||
| 8EZ93U | Medicare ID - Type Unspecified | ||
| 8EZ81U | Medicare ID - Type Unspecified | ||
| 8EZ86U | Medicare ID - Type Unspecified | ||
| 8EZ88U | Medicare ID - Type Unspecified | ||
| AK | MD6411 | Medicaid | |
| 8EZ85L | Medicare ID - Type Unspecified | ||
| 8EZ85U | Medicare ID - Type Unspecified | ||
| 8EZ91U | Medicare ID - Type Unspecified | ||
| 8EZ82U | Medicare ID - Type Unspecified | ||
| 8EZ83U | Medicare ID - Type Unspecified | ||
| 8EZ87U | Medicare ID - Type Unspecified |
