Provider Demographics
NPI:1851386551
Name:STOUT, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
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 1:725 AMERICAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:608-263-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069517A208G00000X
WI62383208G00000X, 204F00000X
IL036080105208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01027332OtherRAILROAD MEDICARE
IN000001005823OtherANTHEM PROVIDER NUMBER FOR TIN 35-2030653
IL036080105Medicaid
IL01605360OtherBCBS PROVIDER ID
IN201019900Medicaid
IL780000280OtherRAILROAD MEDICARE
IN815500006Medicare PIN
INP01027332OtherRAILROAD MEDICARE
INM400058783Medicare PIN
IL780000280Medicare PIN
IL036080105Medicaid
IL01605360OtherBCBS PROVIDER ID
INM400071091Medicare PIN
IN264430001Medicare PIN