Provider Demographics
NPI:1609279504
Name:TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Entity Type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Other - Org Name:INTERACTIVE RESOURCE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
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:
Authorized Official - Phone:336-355-9696
Mailing Address - Street 1:407 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2930
Mailing Address - Country:US
Mailing Address - Phone:336-332-0824
Mailing Address - Fax:336-763-2896
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:336-763-2896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)