Healthcare Provider Details

I. General information

NPI: 1831197938
Provider Name (Legal Business Name): TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 W MEADOWVIEW ROAD
GREENSBORO NC
27406-4316
US

IV. Provider business mailing address

1046 E WENDOVER AVE
GREENSBORO NC
27405-6712
US

V. Phone/Fax

Practice location:
  • Phone: 336-370-9091
  • Fax: 336-370-4922
Mailing address:
  • Phone: 336-272-1050
  • Fax: 336-272-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN K ELLERBY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MSPH CMPE
Phone: 336-272-1050