MEDICARE: TRIAD EP, PC

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	1041C0700X	Clinical Social Worker	CSW002732	GA

General Provider Information

NPI Number	:	1386806412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIAD EP, PC

Provider Business Mailing Address
First Line	:	316 ALEXANDER ST SE
Second Line	:	SUITE 6
City	:	MARIETTA
State	:	GA
Zip	:	30060-2001
Country	:	US
Telephone Number	:	770-331-8760
Fax Number	:	678-581-0146

Provider Business Practice Location Address
First Line	:	316 ALEXANDER ST SE
Second Line	:	SUITE 6
City	:	MARIETTA
State	:	GA
Zip	:	30060-2001
Country	:	US
Telephone Number	:	770-331-8760
Fax Number	:	678-581-0146

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DAVID GLICK
Credential	:	LCSW
Telephone Number	:	770-331-8760

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	01/02/2013

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