Provider Demographics
NPI:1245276724
Name:ROCKY MOUNT INTERNAL MEDICINE,PA
Entity type:Organization
Organization Name:ROCKY MOUNT INTERNAL MEDICINE,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OMATTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIRISENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-443-7678
Mailing Address - Street 1:117 FOY DR
Mailing Address - Street 2:P.O.BOX 7366
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2418
Mailing Address - Country:US
Mailing Address - Phone:252-443-7678
Mailing Address - Fax:252-443-7147
Practice Address - Street 1:117 FOY DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2418
Practice Address - Country:US
Practice Address - Phone:252-443-7678
Practice Address - Fax:252-443-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890149CMedicaid
NC0149COtherBLUE CROSS BLUE SHEILD
NCC86475Medicare UPIN
NC230339Medicare ID - Type Unspecified