Organization
TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Active
Organization
TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Active
Other names
Family Medicine at Eugene Street
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BRIAN K ELLERBY MSPH (CHIEF EXECUTIVE OFFICER)
(336) 355-9696
Entity
Organization
Contact information
Practice address
1002 S EUGENE ST, GREENSBORO, NC 27406-1308
(336) 355-9701
(336) 676-6140
Mailing address
1002 S EUGENE ST, GREENSBORO, NC 27406-1308
(336) 355-9701
(336) 676-6140
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
3336C0002X
Clinic Pharmacy
10670
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
024UF
BCBS
NC
01
—
2348638A
MEDICARE PART B
NC
01
—
34-1962
MEDICARE PART A
NC
05
—
344045A
—
NC
05
—
344045B
—
NC
05
—
344045C
—
NC
01
—
3460247
NCPDP
—
01
—
34D0700291
CLIA
—
01
—
56162
MEDCOST
NC
Enumeration date
10/28/2010
Last updated
11/26/2013
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