Provider Demographics
NPI:1912987090
Name:CAROLINA PEDIATRICS OF THE TRIAD, P.A.
Entity type:Organization
Organization Name:CAROLINA PEDIATRICS OF THE TRIAD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:VENABLE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:336-574-4280
Mailing Address - Street 1:2707 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3669
Mailing Address - Country:US
Mailing Address - Phone:336-574-4280
Mailing Address - Fax:336-574-4634
Practice Address - Street 1:2707 HENRY ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3669
Practice Address - Country:US
Practice Address - Phone:336-574-4280
Practice Address - Fax:336-574-4634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCF83504Medicare UPIN
NCH58733Medicare UPIN
NCF42266Medicare UPIN
NCF42322Medicare UPIN
NCH41422Medicare UPIN
NCF42267Medicare UPIN
NCF42321Medicare UPIN
NCH84574Medicare UPIN
NCG96887Medicare UPIN