Provider Demographics
NPI:1629077490
Name:TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Entity Type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Other - Org Name:GUILFORD CHILD HEALTH-HIGH POINT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
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:MSPH CMPE
Authorized Official - Phone:336-272-1050
Mailing Address - Street 1:1046 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6712
Mailing Address - Country:US
Mailing Address - Phone:336-272-1050
Mailing Address - Fax:336-272-0155
Practice Address - Street 1:400 E COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27260-5221
Practice Address - Country:US
Practice Address - Phone:336-884-0224
Practice Address - Fax:336-884-3471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890245JMedicaid
34D0926775OtherCLIA
NC0272JOtherBCBS
NC2318638AOtherMEDICARE PART B