NPIMap

Organization Active NPI

Triad Adult and Pediatric Medicine, Inc.

  • Federally Qualified Health Center (FQHC)
  • High Point, NC
National Provider Identifier
1528720653
Registry record updated Oct 6, 2021
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
606 N Elm St
High Point, NC 27262-4332
Phone
(336) 884-0224
Fax
(336) 884-3471
NPI assigned
Oct 6, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 6, 2021

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

606 N Elm St
High Point, NC 27262-4332

Mailing address

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

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20220204001230 NC Part A Provider - Federally Qualified Health Center (FQHC) 1850311986 Practice locations: High Point, NC
O20220830003120 NC Part B Supplier - Clinic/Group Practice 1850311986 Receives reassigned benefits from 7 practitioners
Practice locations: High Point, NC

Federally qualified health center certification: CCN 861882

Legal name
TRIAD ADULT AND PEDIATRIC MEDICINE INC
Doing business as
FAMILY MEDICINE AT ELM
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 4, 2022
Last certification
Feb 4, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 13, 2010 in NC
Enrollment address
606 N Elm St
High Point, NC 27262-4332

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
34D2231378Triad Adult & Pediatric Medicine, Inc -606 North Elm Street, High Point, NC 27262Certificate of waiverAug 2, 2027

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

Ownership & related parties

All disclosed owners & managing parties 10

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 OfficerChief Finance Officer (Cfo) Apr 1, 2016
W-2 Managing EmployeeChief Finance Officer (Cfo) Apr 1, 2016
Felicia Reid Individual Corporate DirectorBoard Member Jul 1, 2016
Lakeisha D Harris Individual W-2 Managing Employee Nov 30, 2021
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 OfficerChief Executive Officer (Ceo) Jan 1, 2016
W-2 Managing EmployeeChief Executive Officer (Ceo) 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 7

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

NPI Registry JSON

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

{
    "created_epoch": "1633478400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1633478400000",
    "number": "1528720653",
    "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": "606 N ELM ST",
            "city": "HIGH POINT",
            "state": "NC",
            "postal_code": "272624332",
            "telephone_number": "336-884-0224",
            "fax_number": "336-884-3471"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRIAD ADULT AND PEDIATRIC MEDICINE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-10-06",
        "last_updated": "2021-10-06",
        "certification_date": "2021-08-26",
        "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": []
}

Other providers in High Point, NC

Sources for this page

Verify at the official NPI Registry.