NPIMap

Organization Active NPI

Tri County Community Health Council Inc

  • Federally Qualified Health Center (FQHC)
  • Dublin, NC
National Provider Identifier
1124158043
Registry record updated Mar 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
TRI COUNTY COMMUNITY HEALTH COUNCIL INC
Practice address
73 Dixon Street
Dublin, NC 28332-8903
Phone
(877) 935-5255
Fax
(910) 236-2118
NPI assigned
Mar 7, 2007
Last updated
Mar 27, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 27, 2024

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

Authorized official

Name
William C Ellison
Title
Revenue Cycle Manager
Phone
(910) 567-7065

Specialties & licenses 1

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

Addresses

Primary practice location

73 Dixon Street
Dublin, NC 28332-8903

Mailing address

PO Box 340
Four Oaks, NC 27524-0340
Phone (910) 567-6194

Other identifiers 1

IdentifierTypeStateIssuer
344001DMedicaidNC

Other names 1

  • CommWell Health at Dublin Former legal business name

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040702000780 NC Part B Supplier - Clinic/Group Practice 2163409558 Receives reassigned benefits from 52 practitioners
19 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Willard, NC; Tar Heel, NC; Smithfield, NC; Shallotte, NC; Dunn, NC; Salemburg, NC; Ocean Isle Beach, NC; Harrells, NC…
O20221118000426 NC Part A Provider - Federally Qualified Health Center (FQHC) 2163409558 Practice locations: Dublin, NC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124158043. Details of each certification follow.

Federally qualified health center certification: CCN 341907

Legal name
TRI COUNTY COMMUNITY HEALTH COUNCIL INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 18, 2022
Last certification
Nov 18, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Nov 21, 1977 in NC
Enrollment address
73 Dixon Street
Dublin, NC 28332-8903

Other NPIs with the same Medicare PAC ID 15

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

View all 15

Other NPIs on the same Medicare enrollment 19

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

View all 19

National Provider Directory

National Provider Directory
Tax ID family
Tri County Community Health Council Inc30 organizations share this tax ID, including this one

Other organizations with this tax ID 29

Organizations that report the same tax identification number in the National Provider Directory.

View all 29

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Nancy J Blackman Individual Corporate DirectorBoard of Directors Jul 14, 2021
Phillip E Mills Individual Corporate DirectorBoard of Directors Jul 14, 2021
Vanessa a Burgess Individual Corporate DirectorBoard of Directors Jul 14, 2021
Raymond Lindsey Individual Corporate DirectorBoard of Directors Jul 14, 2021
Kenneth a Cabral Individual Corporate DirectorBoard of Directors Jul 14, 2021
Nathan J Tilghman Individual Corporate DirectorBoard of Directors Jul 14, 2021
Mary Crumpler Individual Corporate DirectorBoard of Directors Jul 14, 2021
Silvia a. Cendejas Individual Corporate DirectorBoard of Directors Jul 14, 2021
Spencer McAlpine Individual Corporate DirectorBoard of Directors Jul 14, 2021
William Taylor Individual Corporate DirectorBoard of Directors Jul 14, 2021
Jose Garcia Individual Corporate DirectorBoard of Directors Jul 14, 2021
Pamela Tripp Individual Corporate OfficerPresident/Ceo Sep 21, 2009
Corporate DirectorPresident/Ceo Sep 21, 2009
W-2 Managing EmployeePresient/Ceo Sep 21, 2009
Operational/Managerial ControlPresient/Ceo Sep 21, 2009
Mary E Blaizes Individual Corporate DirectorBoard of Directors Jul 14, 2021
William C Ellison Individual Corporate OfficerReveneu Cycle Manager Mar 1, 2022

Practitioners & affiliated clinicians

Practitioners 4

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": "1173225600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1711497600000",
    "number": "1124158043",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 340",
            "city": "FOUR OAKS",
            "state": "NC",
            "postal_code": "275240340",
            "telephone_number": "910-567-6194",
            "fax_number": "910-567-5342"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "73 DIXON STREET",
            "city": "DUBLIN",
            "state": "NC",
            "postal_code": "283328903",
            "telephone_number": "877-935-5255",
            "fax_number": "910-236-2118"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI COUNTY COMMUNITY HEALTH COUNCIL INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-07",
        "last_updated": "2024-03-27",
        "certification_date": "2024-03-27",
        "status": "A",
        "authorized_official_last_name": "ELLISON",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "REVENUE CYCLE MANAGER",
        "authorized_official_telephone_number": "910-567-7065"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "344001D",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CommWell Health at Dublin",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Dublin, NC

Sources for this page

Verify at the official NPI Registry.