Provider Demographics
NPI:1285095034
Name:MEDICAL GROUP OF THE TRIAD, PA
Entity type:Organization
Organization Name:MEDICAL GROUP OF THE TRIAD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KWIATKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-242-1125
Mailing Address - Street 1:215 W US HIGHWAY 64
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-2567
Mailing Address - Country:US
Mailing Address - Phone:336-242-1125
Mailing Address - Fax:
Practice Address - Street 1:215 W US HIGHWAY 64
Practice Address - Street 2:SUITE 1
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27295-2567
Practice Address - Country:US
Practice Address - Phone:336-242-1125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1396910345OtherNPI INDIVIDUAL SHENOA RONDEAU
NC1285658906OtherNPI PERSONAL KRISTI MAULDIN
NC1689661761OtherNPI INDIVIDUAL TIM KWIATKOWSKI