Provider Demographics
NPI:1063712727
Name:TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Entity type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ELLERBY
Authorized Official - Suffix:
Authorized Official - Credentials:MSPH
Authorized Official - Phone:336-355-9696
Mailing Address - Street 1:1002 S EUGENE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-1308
Mailing Address - Country:US
Mailing Address - Phone:336-355-9701
Mailing Address - Fax:336-676-6140
Practice Address - Street 1:1002 S EUGENE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-1308
Practice Address - Country:US
Practice Address - Phone:336-355-9701
Practice Address - Fax:336-676-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106703336C0002X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
34D0700291OtherCLIA
NC2348638AOtherMEDICARE PART B
NC344045AMedicaid
3460247OtherNCPDP
NC56162OtherMEDCOST
NC34-1962OtherMEDICARE PART A
NC344045BMedicaid
NC344045CMedicaid
NC024UFOtherBCBS