NPIMap

Organization Active NPI

Bladen Healthcare, LLC

Doing business as Cape Fear Valley BMA Dublin

  • Rural Health Clinic/Center
  • Dublin, NC
National Provider Identifier
1114193695
Registry record updated Nov 19, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
H0154 Issued in NC
Legal business name
BLADEN HEALTHCARE, LLC
Doing business as
Cape Fear Valley BMA Dublin
Practice address
16 3Rd St
Dublin, NC 28332-8903
Phone
(910) 862-3528
Fax
(910) 862-2207
NPI assigned
May 5, 2008
Last updated
Nov 19, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
CUMBERLAND COUNTY HOSPITAL SYSTEM INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 19, 2023

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

Authorized official

Name
Joseph B Fiser
Title
VP Managed Care and Revenue Cycle
Phone
(910) 615-5572

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X H0154 NC Primary

Addresses

Primary practice location

16 3Rd St
Dublin, NC 28332-8903

Mailing address

300 A East McKay Street
Elizabethtown, NC 28337
Phone (910) 862-6308

Other identifiers 1

IdentifierTypeStateIssuer
34-8935AMedicaidNC

Other names 1

  • Cape Fear Valley BMA Dublin Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20080617000314 NC Part B Supplier - Clinic/Group Practice 6800967969 Receives reassigned benefits from 173 practitioners
14 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Elizabethtown, NC; Whiteville, NC; Lumberton, NC; Dublin, NC; Clarkton, NC; Bladenboro, NC
O20121215000023 NC Part A Provider - Rural Health Clinic 6800967969 Practice locations: Dublin, NC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114193695. Details of each certification follow.

Rural health clinic certification: CCN 343444

Legal name
BLADEN HEALTHCARE LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 5, 2013
Last certification
Aug 27, 2021
Ownership / control type
2B
Organization structure
LLCNon-profit
Enrollment address
16 3Rd Street
Dublin, NC 28332-8903
Related CCNs
341315

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 14

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 14

National Provider Directory

National Provider Directory
Part of
Melrose Pediatric Care

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

9858 N Wr Latham Dr
Clarkton, NC 28433
Phone (910) 862-1217

Ownership & related parties

All disclosed owners & managing parties 25

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Veronica Brunell Jones Individual Corporate OfficerTrustee Dec 1, 2022
Operational/Managerial ControlTrustee Dec 1, 2022
Chukwuemeka O Chima Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Shannon Alane Matthews Individual Corporate OfficerTrustee Dec 1, 2022
Operational/Managerial ControlTrustee Dec 1, 2022
Jeannette Council Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Ryan Aul Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Michael Reesal Jones Individual W-2 Managing Employee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Cumberland County Hospital System Inc Organization, Fayetteville, NC Corporation, Non-profit Operational/Managerial Control Aug 20, 2021 100%
Pamela Suggs Story Individual Corporate OfficerTrustee Dec 1, 2022
Operational/Managerial ControlTrustee Dec 1, 2022
Glenn Adams Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Michael Boose Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Girum K Feyissa Individual W-2 Managing EmployeeTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Tammy Thurman Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Michael Nagowski Individual Corporate Director Jun 1, 2008
Sanjay B Shah Individual Corporate OfficerTrustee Dec 1, 2022
Operational/Managerial ControlTrustee Dec 1, 2022
Bret Johnson Individual W-2 Managing EmployeeCfo Jul 29, 2022
Operational/Managerial ControlCfo Jul 29, 2022
Myron Scott Strickland Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Joseph Fiser Individual Corporate DirectorVP Rev Cycle/Managed Care Aug 20, 2021
W-2 Managing EmployeeVP Rev Cycle/Managed Care Aug 20, 2021
William Faircloth Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Warren McDonald Individual Corporate OfficerBoard of Director Jul 29, 2022
Operational/Managerial ControlBoard of Director Jul 29, 2022
Samuel a Fleishman Individual W-2 Managing EmployeeMedical Director Jul 29, 2022
Operational/Managerial ControlMedical Director Jul 29, 2022
James Keefe Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Murtis Worth Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Toni Stewart Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022
Alicia Monae Marks Flowers Individual Corporate OfficerTrustee Dec 1, 2022
Operational/Managerial ControlTrustee Dec 1, 2022
Bradley J Broussard Individual Corporate OfficerTrustee Jul 29, 2022
Operational/Managerial ControlTrustee Jul 29, 2022

Owners & managing parties with NPI records 17

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 17

Facilities with the same owner 14

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 14

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1209945600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700352000000",
    "number": "1114193695",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 A EAST MCKAY STREET",
            "city": "ELIZABETHTOWN",
            "state": "NC",
            "postal_code": "28337",
            "telephone_number": "910-862-6308",
            "fax_number": "910-862-5501"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16 3RD ST",
            "city": "DUBLIN",
            "state": "NC",
            "postal_code": "283328903",
            "telephone_number": "910-862-3528",
            "fax_number": "910-862-2207"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLADEN HEALTHCARE, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CUMBERLAND COUNTY HOSPITAL SYSTEM INC",
        "enumeration_date": "2008-05-05",
        "last_updated": "2023-11-19",
        "certification_date": "2023-11-19",
        "status": "A",
        "authorized_official_last_name": "FISER",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "VP MANAGED CARE AND REVENUE CYCLE",
        "authorized_official_telephone_number": "910-615-5572"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NC",
            "license": "H0154",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "34-8935A",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cape Fear Valley BMA Dublin",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dublin, NC

Sources for this page

Verify at the official NPI Registry.