Basic Information
Provider Information
NPI: 1710961172
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: STOUT
FirstName: KERRICK
MiddleName: LOUIS
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 130
Address2:  
City: DILLINGHAM
State: AK
PostalCode: 995760130
CountryCode: US
TelephoneNumber: 9078429218
FaxNumber: 9078429500
Practice Location
Address1: 6000 KANAKANAK RD
Address2:  
City: DILLINGHAM
State: AK
PostalCode: 99576
CountryCode: US
TelephoneNumber: 9078425201
FaxNumber: 9078429250
Other Information
ProviderEnumerationDate: 11/30/2005
LastUpdateDate: 03/11/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X4902AKY Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000X34237KYN Allopathic & Osteopathic PhysiciansFamily Medicine 
207P00000X34237KYN Allopathic & Osteopathic PhysiciansEmergency Medicine 

ID Information
IDTypeStateIssuerDescription
MD641105AK MEDICAID


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