Basic Information
| Provider Information | |||||||||
| NPI: | 1063901312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIANGLE SPRINGS PHYSICIAN GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S 5TH ST | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4125883546 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10901 WORLD TRADE BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276174203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197468900 | ||||||||
| FaxNumber: | 9195785544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2018 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
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| AuthorizedOfficialTitleorPosition: | EVO - CFO | ||||||||
| AuthorizedOfficialTelephone: | 4125883546 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPRINGSTONE, LLC | ||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1063901312 | 05 | NC | MEDICAID |