Provider Demographics
NPI:1386862688
Name:WILSON INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:WILSON INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEDHAT
Authorized Official - Middle Name:F
Authorized Official - Last Name:SIDAROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-291-8600
Mailing Address - Street 1:PO BOX 3544
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27895-3544
Mailing Address - Country:US
Mailing Address - Phone:252-291-8600
Mailing Address - Fax:252-291-6914
Practice Address - Street 1:2402 CAMDEN ST SW STE B500
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-8608
Practice Address - Country:US
Practice Address - Phone:252-291-8600
Practice Address - Fax:252-291-6914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600733207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900812Medicaid
NC2040262FMedicare PIN
NC5900812Medicaid
NC2040262CMedicare PIN