1114476389 NPI number — PHYSICIAN PRACTICE OF MADISON, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114476389 NPI number — PHYSICIAN PRACTICE OF MADISON, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN PRACTICE OF MADISON, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHYSICIAN PRACTICE OF MADISON, PC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114476389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 EASTBROOKE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-6537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-721-2417
Provider Business Mailing Address Fax Number:
601-510-2367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 N FRONTAGE RD FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICKSBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39180-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-721-2417
Provider Business Practice Location Address Fax Number:
601-510-2367
Provider Enumeration Date:
09/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SULTAN
Authorized Official First Name:
SHAHJAHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
412-721-2417

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  21500 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04377714 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 351416 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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