Provider Demographics
NPI:1417974064
Name:TRIANGLE MEDICAL PROFESSIONALS LLC
Entity Type:Organization
Organization Name:TRIANGLE MEDICAL PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PA
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLELLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:919-870-8845
Mailing Address - Street 1:6512 SIX FORKS RD
Mailing Address - Street 2:SUITE 102B
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6561
Mailing Address - Country:US
Mailing Address - Phone:919-870-8845
Mailing Address - Fax:
Practice Address - Street 1:8512 SIX FORKS RD
Practice Address - Street 2:SUITE 102B
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3255
Practice Address - Country:US
Practice Address - Phone:919-870-8845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC132522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC132522OtherGROUP MEDICAL BOARD LICEN
NC=========OtherTAX ID