Provider Demographics
NPI:1356446363
Name:TRIAD INTERNAL MEDICINE ASSOCIATES PA
Entity Type:Organization
Organization Name:TRIAD INTERNAL MEDICINE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:GILLIAM
Authorized Official - Last Name:SELLARS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-230-0402
Mailing Address - Street 1:1593 YANCEYVILLE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6948
Mailing Address - Country:US
Mailing Address - Phone:336-230-0402
Mailing Address - Fax:336-230-1761
Practice Address - Street 1:1593 YANCEYVILLE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6948
Practice Address - Country:US
Practice Address - Phone:336-230-0402
Practice Address - Fax:336-230-1761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCI5242OtherRAILROAD MEDICARE
NC890296UMedicaid
NC890296UMedicaid