Provider Demographics
NPI:1194267336
Name:TRIAD MEDICAL GROUP PA
Entity type:Organization
Organization Name:TRIAD MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:NEKITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-790-9787
Mailing Address - Street 1:2031 MARTIN LUTHER KING JR DR STE A
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-3300
Mailing Address - Country:US
Mailing Address - Phone:336-790-9787
Mailing Address - Fax:336-790-9786
Practice Address - Street 1:2031 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-3342
Practice Address - Country:US
Practice Address - Phone:704-838-0516
Practice Address - Fax:704-838-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39460207Q00000X, 207R00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty