Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204F00000X | Transplant Surgeon | 62383 | WI |
N | 208G00000X | Cardiothoracic Vascular Surgeon | 01069517A | IN |
N | 208G00000X | Cardiothoracic Vascular Surgeon | 036080105 | IL |
N | 208G00000X | Cardiothoracic Vascular Surgeon | 62383 | WI |
NPI | 1851386551 |
---|---|
Provider Name | Mark J Stout |
First Address | Waukesha, WI 53188-5031 |
Second Address | Waukesha, WI 53188-5031 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2005 |
Last Update Date | 03/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000001005823 | ANTHEM PROVIDER NUMBER FOR TIN 35-2030653 (01) | IN |
01605360 | BCBS PROVIDER ID (01) | IL |
036080105 | (05) | IL |
201019900 | (05) | IN |
780000280 | RAILROAD MEDICARE (01) | IL |
F28512 | (02) | IL |
P01027332 | RAILROAD MEDICARE (01) | IN |