Provider Demographics
NPI:1639312879
Name:NORTHERN TRIAD SURGICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:NORTHERN TRIAD SURGICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-634-0095
Mailing Address - Street 1:1818 RICHARDSON DR.
Mailing Address - Street 2:STE. E
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320
Mailing Address - Country:US
Mailing Address - Phone:336-634-0095
Mailing Address - Fax:336-616-0320
Practice Address - Street 1:1818 RICHARDSON DR
Practice Address - Street 2:STE. E
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5451
Practice Address - Country:US
Practice Address - Phone:336-634-0095
Practice Address - Fax:336-616-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200002376723208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty