Provider Demographics
NPI:1952874075
Name:STOUT, SCOTT E (LNHA)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:E
Last Name:STOUT
Suffix:
Gender:M
Credentials:LNHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-1504
Mailing Address - Country:US
Mailing Address - Phone:618-294-8696
Mailing Address - Fax:618-294-8699
Practice Address - Street 1:410 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:CASEY
Practice Address - State:IL
Practice Address - Zip Code:62420-1014
Practice Address - Country:US
Practice Address - Phone:217-932-4081
Practice Address - Fax:217-932-4922
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002923314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14E422OtherMEDICAID ICF/DD CERTIFICATION