Provider Demographics
NPI:1114476389
Name:PHYSICIAN PRACTICE OF MADISON, PC
Entity Type:Organization
Organization Name:PHYSICIAN PRACTICE OF MADISON, PC
Other - Org Name:PHYSICIAN PRACTICE OF MADISON, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHJAHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SULTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-721-2417
Mailing Address - Street 1:6 EASTBROOKE CIR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6537
Mailing Address - Country:US
Mailing Address - Phone:412-721-2417
Mailing Address - Fax:601-510-2367
Practice Address - Street 1:1111 N FRONTAGE RD FL 2
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5102
Practice Address - Country:US
Practice Address - Phone:412-721-2417
Practice Address - Fax:601-510-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04377714Medicaid
MS351416OtherMEDICARE PTAN