Provider Demographics
NPI:1962741421
Name:TRIAD ADULT AND PEDIATRIC MEDICINE, INC
Entity type:Organization
Organization Name:TRIAD ADULT AND PEDIATRIC MEDICINE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-355-9715
Mailing Address - Street 1:1002 S EUGENE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-1308
Mailing Address - Country:US
Mailing Address - Phone:336-355-9715
Mailing Address - Fax:336-763-2896
Practice Address - Street 1:922 THIRD AVE
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-4440
Practice Address - Country:US
Practice Address - Phone:336-355-9913
Practice Address - Fax:336-637-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1962741421Medicaid