Healthcare Provider Details

I. General information

NPI: 1023318961
Provider Name (Legal Business Name): TRIAD ADULT AND PEDIATRIC MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 QUAKER LN STE 100C
HIGH POINT NC
27262-3832
US

IV. Provider business mailing address

1046 E WENDOVER AVE
GREENSBORO NC
27405-6712
US

V. Phone/Fax

Practice location:
  • Phone: 336-878-6027
  • Fax: 336-878-6189
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
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

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