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General NPI Number Information
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NPI Number | 1114476389
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Entity Type | Organization
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Legal Business Name | PHYSICIAN PRACTICE OF MADISON, PC
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Dates
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Enumeration Date | 09/28/2016
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Last Update Date | 09/28/2016
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Provider Practice Location Address
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Address Line | 1111 N FRONTAGE RD FL 2
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City | VICKSBURG
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State | MS
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Zip | 39180-5102
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Country | US
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Telephone | 412-721-2417
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Fax | 601-510-2367
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Provider Business Mailing Address
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Address Line | 6 EASTBROOKE CIR
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City | MADISON
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State | MS
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Zip | 39110-6537
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Country | US
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Telephone | 412-721-2417
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Fax | 601-510-2367
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Authorized Official
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Title or Position | CEO
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Name | DR. SHAHJAHAN SULTAN
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Credential | M.D.
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Telephone | 412-721-2417
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 21500
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License Number State | MS
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