Physician Practice of Madison, PC

Primary specialty

SpecialistTaxonomy code 174400000X

License

21500 Issued in MS

Legal business name

PHYSICIAN PRACTICE OF MADISON, PC

Doing business as

Physician Practice of Madison, PC

Practice address

1111 N Frontage Rd FL 2
Vicksburg, MS 39180-5102

Phone

(412) 721-2417

Fax

(601) 510-2367

NPI assigned

Sep 28, 2016

Last updated

Sep 28, 2016By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Shahjahan Sultan, M.D.

Title

Ceo

Phone

(412) 721-2417

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Physician Practice of Madison, PC Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1475020800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1475020800000",
    "number": "1114476389",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6 EASTBROOKE CIR",
            "city": "MADISON",
            "state": "MS",
            "postal_code": "391106537",
            "telephone_number": "412-721-2417",
            "fax_number": "601-510-2367"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1111 N FRONTAGE RD FL 2",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391805102",
            "telephone_number": "412-721-2417",
            "fax_number": "601-510-2367"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHYSICIAN PRACTICE OF MADISON, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-09-28",
        "last_updated": "2016-09-28",
        "status": "A",
        "authorized_official_last_name": "SULTAN",
        "authorized_official_first_name": "SHAHJAHAN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "412-721-2417",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "MS",
            "license": "21500",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "04377714",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "351416",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Physician Practice of Madison, PC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Beverly B Pettigrew
• Hein Phan, M.D.
• Danielle Phelps
• Physical Therapy Occupational Therapy Speech Therapy
• Physician Management Services of Mississippi, LLC
• Physicians Sleep Diagnostics, Inc
• Paul W Pierce IV, M.D.
• Holland J Pitre, MD
• Holly Pittman, OT
• Sarah Grace Pittman, PHARMD

• Specialist in Vicksburg, MS
• Providers in Vicksburg, MS by specialty
• Specialist in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 28, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.