1114476389 NPI number — PHYSICIAN PRACTICE OF MADISON, PC

Table of content: (NPI 1114476389)

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:
Provider Other Organization Name Type Code:
6
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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