Triad Adult and Pediatric Medicine, Inc

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

TRIAD ADULT AND PEDIATRIC MEDICINE, INC

Practice address

922 Third Ave
Reidsville, NC 27320-4440

Phone

(336) 355-9913

Fax

(336) 637-8091

NPI assigned

Feb 4, 2013

Last updated

Apr 20, 2015By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Mrs. Michelle A. Lewis

Title

Interim Chief Executive Officer

Phone

(336) 355-9715

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Clara F. Gunn Medical Center Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962741421. Details of each certification follow.

• CCN 341013 Federally qualified health center · Active · Name & address match · Details

Federally qualified health center certification: CCN 341013

Legal name

CLARA F GUNN (CFG)

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

May 27, 2014

Last certification

May 27, 2014

Ownership / control type

For profit – corporation

Facility address

922 Third Avenue
Reidsville, NC 27320

Locations

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

{
    "created_epoch": "1359936000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1429488000000",
    "number": "1962741421",
    "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": "336-355-9715",
            "fax_number": "336-763-2896"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "922 THIRD AVE",
            "city": "REIDSVILLE",
            "state": "NC",
            "postal_code": "273204440",
            "telephone_number": "336-355-9913",
            "fax_number": "336-637-8091"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRIAD ADULT AND PEDIATRIC MEDICINE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-04",
        "last_updated": "2015-04-20",
        "status": "A",
        "authorized_official_last_name": "LEWIS",
        "authorized_official_first_name": "MICHELLE",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "INTERIM CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "336-355-9715",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1962741421",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Clara F. Gunn Medical Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Sabrina Ann Tillman, PLCSW
• Brenda Johnson Torain
• Total Renal Care of North Carolina LLC (Reidsville Dialysis)
• Tri State Psychotherapy
• Tri-Care Professional Services, LLC
• Triad Medicine and Pediatric Associates, PLLC
• Trucare Behavioral Health Services, L.L.P.
• Elizabeth Tucker
• Melanie J Tudor
• Umanity Family Care Home LLC

• Federally Qualified Health Center (FQHC) in Reidsville, NC
• Providers in Reidsville, NC by specialty
• Federally Qualified Health Center (FQHC) in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.