Provider Demographics
NPI:1942730148
Name:STOUT, MOLLY AMORY (MD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:AMORY
Last Name:STOUT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:AMORY
Other - Last Name:STORER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-7000
Mailing Address - Fax:
Practice Address - Street 1:363 W. ERIE STREET
Practice Address - Street 2:SUITE 350
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:312-995-1955
Practice Address - Fax:312-995-1956
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-071619207N00000X
MA271913390200000X
IL036.156344207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program