Healthcare Provider Details

I. General information

NPI: 1194267336
Provider Name (Legal Business Name): TRIAD MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 MARTIN LUTHER KING JR DR
GREENSBORO NC
27406-3342
US

IV. Provider business mailing address

2031 MARTIN LUTHER KING JR DR STE A
GREENSBORO NC
27406-3300
US

V. Phone/Fax

Practice location:
  • Phone: 704-838-0516
  • Fax: 704-838-0565
Mailing address:
  • Phone: 336-790-9787
  • Fax: 336-790-9786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39460
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39460
License Number StateNC

VIII. Authorized Official

Name: NEKITA CLYBURN
Title or Position: BILLING ADMINISTRATION
Credential:
Phone: 336-790-9787