NPIMap

Organization Active NPI

Triad Adult and Pediatric Medicine, Inc.

  • Federally Qualified Health Center (FQHC)
  • High Point, NC
National Provider Identifier
1972050979
Registry record updated Sep 7, 2016
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
2039 Brentwood St
High Point, NC 27263-1805
Phone
(336) 355-9722
Fax
(336) 763-2896
NPI assigned
Sep 7, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 7, 2016

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

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

2039 Brentwood St
High Point, NC 27263-1805

Mailing address

1002 S Eugene St
Greensboro, NC 27406-1308
Phone (336) 355-9715

Other names 1

  • TAPM Family Medicine at Brentwood Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20161130000401 NC Part A Provider - Federally Qualified Health Center (FQHC) 1850311986 Practice locations: High Point, NC

Federally qualified health center certification: CCN 341051

Legal name
TRIAD ADULT AND PEDIATRIC MEDICINE INC
Doing business as
TAPM FAMILY MEDICINE AT BRENTWOOD
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 30, 2016
Last certification
Nov 30, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 13, 2010 in NC
Enrollment address
2039 Brentwood St
High Point, NC 27263-1805

Other NPIs with the same Medicare PAC ID 5

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 12

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
Merle Green Individual Corporate DirectorBoard Member Oct 8, 2010
Lakeisha D Harris Individual W-2 Managing EmployeeCredentialing & Compliance Manag Sep 12, 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 Corporate DirectorCeo Jan 1, 2016
Shaketa Berrie Individual Corporate DirectorBoard Member Apr 1, 2014
Clarence Williamson Individual Corporate DirectorBoard Member 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 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": "1473206400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1473206400000",
    "number": "1972050979",
    "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": "2039 BRENTWOOD ST",
            "city": "HIGH POINT",
            "state": "NC",
            "postal_code": "272631805",
            "telephone_number": "336-355-9722",
            "fax_number": "336-763-2896"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRIAD ADULT AND PEDIATRIC MEDICINE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-09-07",
        "last_updated": "2016-09-07",
        "status": "A",
        "authorized_official_last_name": "LEWIS",
        "authorized_official_first_name": "MICHELLE",
        "authorized_official_middle_name": "ANITA",
        "authorized_official_title_or_position": "CEO",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "TAPM Family Medicine at Brentwood",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in High Point, NC

Sources for this page

Verify at the official NPI Registry.