=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457792699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SULTAN SERETIS BUSSEY HOSPITALIST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2013
-----------------------------------------------------
Last Update Date | 01/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 ROUTE 45
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08079-2064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-912-0412
-----------------------------------------------------
Fax | 856-221-7278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 461
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08079-0461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-912-0412
-----------------------------------------------------
Fax | 856-221-7278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | DR. WAMIQ SULTAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 856-912-0412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA06336400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------