Provider Demographics
NPI:1023566007
Name:STOUTAMIRE, BENTON (CNIM)
Entity type:Individual
Prefix:MR
First Name:BENTON
Middle Name:
Last Name:STOUTAMIRE
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 CHARTER BLVD STE 402A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4854
Mailing Address - Country:US
Mailing Address - Phone:478-273-3831
Mailing Address - Fax:855-940-0206
Practice Address - Street 1:420 CHARTER BLVD STE 402A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4854
Practice Address - Country:US
Practice Address - Phone:478-273-3831
Practice Address - Fax:303-922-4640
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic