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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