Basic Information
| Provider Information | |||||||||
| NPI: | 1619198801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOUTAMIRE | ||||||||
| FirstName: | BARNEY | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91407 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571091407 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1210 W 18TH ST | ||||||||
| Address2: | STE LL03 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571044647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053281410 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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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 | 2085B0100X | 201000986 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | 4301085978 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 8399 | SD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 158TR | 01 | NC | BCBS NC STATE | OTHER | 2076199 | 01 | NC | MEDICARE | OTHER | 5915655 | 05 | NC | MEDICAID | 02898 | 01 | NC | WORK COMP | OTHER | 158TR | 01 | NC | BCBS | OTHER |