Organization
PHYSICIAN PRACTICE OF MADISON, PC
Active
Other names
Physician Practice of Madison, PC
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHAHJAHAN SULTAN M.D. (CEO)
(412) 721-2417
Entity
Organization
Contact information
Practice address
1111 N FRONTAGE RD FL 2, VICKSBURG, MS 39180-5102
(412) 721-2417
(601) 510-2367
Mailing address
6 EASTBROOKE CIR, MADISON, MS 39110-6537
(412) 721-2417
(601) 510-2367
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
21500
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04377714
—
MS
01
—
351416
MEDICARE PTAN
MS
Enumeration date
09/28/2016
Last updated
09/28/2016
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