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General NPI Number Information
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NPI Number | 1639312879
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Entity Type | Organization
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Legal Business Name | NORTHERN TRIAD SURGICAL ASSOCIATES, PLLC
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Dates
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Enumeration Date | 04/17/2009
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Last Update Date | 07/12/2013
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Provider Practice Location Address
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Address Line | 1818 RICHARDSON DR STE. E
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City | REIDSVILLE
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State | NC
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Zip | 27320-5451
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Country | US
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Telephone | 336-634-0095
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Fax | 336-616-0320
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Provider Business Mailing Address
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Address Line | 1818 RICHARDSON DR. STE. E
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City | REIDSVILLE
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State | NC
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Zip | 27320
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Country | US
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Telephone | 336-634-0095
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Fax | 336-616-0320
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Authorized Official
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Title or Position | MEMBER
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Name | MARK A JENKINS
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Credential | M.D.
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Telephone | 336-634-0095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 200002376723
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License Number State | NC
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