NPIMap

Organization Active NPI

Triad Adult and Pediatric Medicine, Inc.

  • Federally Qualified Health Center (FQHC)
  • Greensboro, NC
National Provider Identifier
1447980883
Registry record updated Jun 16, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Practice address
300 W Northwood St
Greensboro, NC 27401-1324
Phone
(336) 355-9696
Fax
(336) 676-6170
NPI assigned
Jun 16, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 16, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lakeisha Harris
Title
Credentialing Manager
Phone
(336) 355-9701

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

300 W Northwood St
Greensboro, NC 27401-1324

Mailing address

1002 S Eugene St
Greensboro, NC 27406-1308
Phone (336) 355-9701

Other names 1

  • Family Medicine at Northwood Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20221005002021 NC Part A Provider - Federally Qualified Health Center (FQHC) 1850311986 Practice locations: Greensboro, NC
O20221229000473 NC Part B Supplier - Clinic/Group Practice 1850311986 Receives reassigned benefits from 7 practitioners
Practice locations: Greensboro, NC

Federally qualified health center certification: CCN 341175

Legal name
TRIAD ADULT AND PEDIATRIC MEDICINE INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 2, 2022
Last certification
Sep 2, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 13, 2010 in NC
Enrollment address
300 W Northwood St
Greensboro, NC 27401-1324

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D2261773Triad Adult & Pediatric Medicine-Family Medicine300 W Northwood Street, Greensboro, NC 27401Certificate of waiverJun 5, 2028

National Provider Directory

National Provider Directory
Tax ID family
Triad Adult and Pediatric Medicine Inc16 organizations share this tax ID, including this one

Other organizations with this tax ID 15

Organizations that report the same tax identification number in the National Provider Directory.

View all 15

Locations

400 E Commerce Ave
High Point, NC 27260
Phone (336) 884-0224

2039 Brentwood St
High Point, NC 27263
Phone (336) 355-9722

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Tiffany Grant Individual Corporate DirectorBoard Member Apr 1, 2020
James Thomas Individual Corporate DirectorBoard Member Feb 1, 2021
Danielle Cole Individual Corporate OfficerCfo Apr 1, 2016
W-2 Managing Employee Apr 1, 2016
Felicia Reid Individual Corporate DirectorBoard Member Jul 1, 2016
Lakeisha D Harris Individual W-2 Managing Employee Aug 1, 2013
Milagros Amaro Individual Corporate DirectorBoard Member Mar 25, 2022
Christopher Rivera Individual Corporate DirectorBoard Member Jul 1, 2016
Sofia Crisp Individual Corporate DirectorBoard Member Jun 1, 2020
Jasmine Beard Individual Corporate DirectorBoard Member Apr 1, 2020
Michelle a Lewis Individual Corporate OfficerCeo Jan 1, 2016
W-2 Managing Employee Jan 1, 2016
Clarence Williamson Individual Corporate DirectorBoard Member Jan 1, 2016

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Family Medicine at Eugene StreetGreensboro, NC, CCN 341962 Federally qualified health center Operational/Managerial Control Aug 29, 2011

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1655337600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1655337600000",
    "number": "1447980883",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1002 S EUGENE ST",
            "city": "GREENSBORO",
            "state": "NC",
            "postal_code": "274061308",
            "telephone_number": "336-355-9701",
            "fax_number": "336-763-2896"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 W NORTHWOOD ST",
            "city": "GREENSBORO",
            "state": "NC",
            "postal_code": "274011324",
            "telephone_number": "336-355-9696",
            "fax_number": "336-676-6170"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRIAD ADULT AND PEDIATRIC MEDICINE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-06-16",
        "last_updated": "2022-06-16",
        "certification_date": "2022-06-16",
        "status": "A",
        "authorized_official_last_name": "HARRIS",
        "authorized_official_first_name": "LAKEISHA",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "336-355-9701"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Medicine at Northwood",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Family Medicine at Northwood",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Greensboro, NC

Sources for this page

Verify at the official NPI Registry.