NPIMap

Organization Active NPI

Triad Adult and Pediatric Medicine, Inc.

Doing business as Family Medicine at Arlington Street

  • Family Medicine Physician
  • Greensboro, NC
National Provider Identifier
1881059723
Registry record updated Apr 21, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Doing business as
Family Medicine at Arlington Street
Practice address
1002 S Eugene St
Greensboro, NC 27406-1308
Phone
(336) 355-9696
Fax
(336) 763-2896
NPI assigned
Dec 18, 2015
Last updated
Apr 21, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 21, 2016

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

Authorized official

Name
Mrs. Michelle Lewis
Title
Ceo
Phone
(336) 355-9715

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

1002 S Eugene St
Greensboro, NC 27406-1308

Mailing address

1205 Arlington St
Greensboro, NC 27406-1420
Phone (336) 355-9696

Other names 1

  • Family Medicine at Arlington Street Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20170310002097 NC Part A Provider - Federally Qualified Health Center (FQHC) 1850311986 Practice locations: Greensboro, NC
O20170810003305 NC Part B Supplier - Clinic/Group Practice 1850311986 Receives reassigned benefits from 4 practitioners
Practice locations: Greensboro, NC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881059723. Details of each certification follow.

Federally qualified health center certification: CCN 341065

Legal name
TRIAD ADULT AND PEDIATRIC MEDICINE INC
Doing business as
FAMILY MEDICINE AT ARLINGTON STREET
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 14, 2017
Last certification
Mar 14, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 13, 2010 in NC
Enrollment address
1205 Arlington St
Greensboro, NC 27406-1420

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
34D2105367Family Medicine at Arlington1205 Arlington Street, Greensboro, NC 27406Certificate of waiverNov 23, 2027

National Provider Directory

National Provider Directory
Tax ID family
Guilford Child Health 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 11

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

NameRoleSinceShare
Leila Lewis Individual Corporate DirectorBoard Member Mar 27, 2015
Danielle Cole Individual Corporate OfficerCfo Mar 24, 2016
Lakeisha D Harris Individual W-2 Managing EmployeeCredentialing & Compliance Manag Dec 21, 2016
Christopher Rivera Individual Corporate OfficerBoard Member Jul 1, 2016
Sadie H Blue Individual Corporate DirectorBoard Member-Board Chairperson Jul 1, 2014
Jasmine Beard Individual Corporate DirectorBoard Member-Vice Chairperson Jan 29, 2015
Angela Tuggle Individual Corporate OfficerBoard Member Jul 1, 2016
Michelle a Lewis Individual 5% Or Greater Indirect Ownership Interest Oct 22, 2024
Corporate DirectorCeo Jan 1, 2016
Shaketa Berrie Individual Corporate DirectorBoard Member Apr 1, 2014
Clarence Williamson Individual Corporate DirectorDirector Dec 18, 2015
Maxine Y Salazar Individual Corporate DirectorBoard Member Aug 28, 2014

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 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1450396800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1461196800000",
    "number": "1881059723",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1205 ARLINGTON ST",
            "city": "GREENSBORO",
            "state": "NC",
            "postal_code": "274061420",
            "telephone_number": "336-355-9696",
            "fax_number": "336-763-2896"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1002 S EUGENE ST",
            "city": "GREENSBORO",
            "state": "NC",
            "postal_code": "274061308",
            "telephone_number": "336-355-9696",
            "fax_number": "336-763-2896"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRIAD ADULT AND PEDIATRIC MEDICINE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-12-18",
        "last_updated": "2016-04-21",
        "status": "A",
        "authorized_official_last_name": "LEWIS",
        "authorized_official_first_name": "MICHELLE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "336-355-9715",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Family Medicine at Arlington Street",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Greensboro, NC

Sources for this page

Verify at the official NPI Registry.