Basic Information
| Provider Information | |||||||||
| NPI: | 1497756597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOUT | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3670 PARKER BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195641544 | ||||||||
| FaxNumber: | 7199241593 | ||||||||
| Practice Location | |||||||||
| Address1: | 3670 PARKER BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195641544 | ||||||||
| FaxNumber: | 7199241593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 33411 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | 33411 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 48744 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | P00997270 | 01 | CO | RAILROAD MEDICARE | OTHER | 01180773 | 05 | CO | MEDICAID |