Provider Demographics
NPI:1023318961
Name:TRIAD ADULT AND PEDIATRIC MEDICINE INC
Entity type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MEDICINE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLERBY
Authorized Official - Suffix:
Authorized Official - Credentials:MSPH
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 1:624 QUAKER LN STE 100C
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-3832
Practice Address - Country:US
Practice Address - Phone:336-878-6027
Practice Address - Fax:336-878-6189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34-1964OtherMEDICARE A
NC344044CMedicaid
NC344044AMedicaid
NC344044BMedicaid
NC56162OtherMEDCOST
3460235OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC024UEOtherBCBS OF NC
NC34D1002754OtherCLIA