MEDICARE: TRIAD ADULT AND PEDIATRIC MEDICINE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710049986
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIAD ADULT AND PEDIATRIC MEDICINE, INC.

Provider Business Mailing Address
First Line	:	1046 E WENDOVER AVE
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27405-6712
Country	:	US
Telephone Number	:	336-272-1050
Fax Number	:	336-272-0155

Provider Business Practice Location Address
First Line	:	433 W. MEADOWVIEW ROAD
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-4316
Country	:	US
Telephone Number	:	336-370-9091
Fax Number	:	336-370-4922

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. BRIAN K ELLERBY
Credential	:	MSPH,CMPE
Telephone Number	:	336-272-1050

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	08/19/2011

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