Provider Demographics
NPI:1730296112
Name:STOUT, ERIC CAMERON (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:CAMERON
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 1:2500 STARLING ST STE 305
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4265
Mailing Address - Country:US
Mailing Address - Phone:912-554-0542
Mailing Address - Fax:912-554-0475
Practice Address - Street 1:2500 STARLING ST STE 305
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4265
Practice Address - Country:US
Practice Address - Phone:912-554-0542
Practice Address - Fax:912-554-0475
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056629208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20-3106721OtherTAX ID
GA660215053AMedicaid