Provider Demographics
NPI:1447980883
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:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAKEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-355-9701
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:336-355-9701
Mailing Address - Fax:336-763-2896
Practice Address - Street 1:300 W NORTHWOOD ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1324
Practice Address - Country:US
Practice Address - Phone:336-355-9696
Practice Address - Fax:336-676-6170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)