Provider Demographics
NPI:1104884477
Name:MARK RODAMMER OD PC
Entity type:Organization
Organization Name:MARK RODAMMER OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-442-0802
Mailing Address - Street 1:PO BOX 7396
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804
Mailing Address - Country:US
Mailing Address - Phone:252-442-0802
Mailing Address - Fax:252-442-2820
Practice Address - Street 1:511 BELFIELD DR
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1217
Practice Address - Country:US
Practice Address - Phone:252-442-0802
Practice Address - Fax:252-442-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010285691Medicaid
VA010338352Medicaid
VA010320445Medicaid
VAC09840Medicare PIN
VA5632440002Medicare NSC