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NPI Code Detail

MEDICARE: TRIAD ADULT AND PEDIATRIC MEDICINE, INC.

MEDICARE: TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
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
1261QF0400XFederally Qualified Health Center (FQHC)

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
42318638AOTHERNCMEDICARE PART B

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
234D0926775OTHERCLIA
30272JOTHERNCBCBS

General Provider Information

NPI Number : 1629077490
Entity Type Code : Organization
Provider Name (Legal Business Name) : TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Provider Business Mailing Address
First Line : 1046 E WENDOVER AVE
Second Line :
City : GREENSBORO
State : NC
Zip : 27405-6712
Country : US
Telephone Number : 336-272-1050
Fax Number : 336-272-0155
Provider Business Practice Location Address
First Line : 400 E COMMERCE AVE
Second Line :
City : HIGH POINT
State : NC
Zip : 27260-5221
Country : US
Telephone Number : 336-884-0224
Fax Number : 336-884-3471
Authorized Official
Title or Position : CHIEF EXECUTIVE OFFICER
Name : MR. BRIAN K. ELLERBY
Credential : MSPH CMPE
Telephone Number : 336-272-1050
Provider Enumeration Date : 07/14/2005
Last Update Date : 08/29/2011

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