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Black River Health Services Inc

Organization Active NPI Federally Qualified Health Center (FQHC) · Atkinson, NC

NPI 1174511976 · NPPES record last updated Dec 12, 2019

Key facts

NPI
1174511976
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
BLACK RIVER HEALTH SERVICES INC
Practice address
109 W Church St
Atkinson, NC 28421-9230
Phone
(910) 283-7783
Fax
(910) 283-7927
NPI assigned
Oct 6, 2005
Organization subpart
No

Authorized official

Name
Lee Ann Amann
Title
Administrator
Phone
(910) 259-6973

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 2

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

Other NPIs with the same Medicare PAC ID 3

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

Member of 1

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

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in NC

Federally qualified health center certification: CCN 341086

Legal name
BLACK RIVER HEALTH SERVICES INC
Doing business as
BLACK RIVER HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 31, 2018
Last certification
Jul 31, 2018
Ownership / control type
For profit – corporation
Organization structure
Corporation · Non-profit
Incorporated
Apr 2, 1973 in NC
Enrollment address
109 W Church St
Atkinson, NC 28421-9230

All disclosed owners & managing parties 12

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

NameRoleSinceShare
William Marshburn
Individual 		5% Or Greater Indirect Ownership Interest Jan 1, 1998 10%
Corporate Officer
President Board of Directors		 Oct 24, 2008 10%
Ernie Johnson
Individual 		5% Or Greater Indirect Ownership Interest
Board Member		 Jul 25, 2011 10%
Corporate Officer
Board Member		 Jul 25, 2011 10%
Caroleigh Sholar
Individual 		5% Or Greater Indirect Ownership Interest Jan 26, 1998 10%
Corporate Officer
Board Member		 Jan 26, 1998 10%
Lorie Floyd
Individual 		5% Or Greater Indirect Ownership Interest Sep 26, 2014 10%
Corporate Officer
Board Member		 Sep 29, 2014 10%
Lee Ann Amann
Individual 		Corporate Officer
Ceo		 Jun 16, 2015
Corporate Director
Ceo		 Jun 16, 2015
W-2 Managing Employee
Ceo		 Jun 16, 2015
Judy Blanchard
Individual 		5% Or Greater Indirect Ownership Interest Jan 17, 2011 10%
Corporate Officer
Board Member		 Jan 17, 2011 10%
Edward Brown
Individual 		Corporate Officer
Treasurer Board of Directors		 Jun 27, 2014 10%
Sandra Rooks
Individual 		5% Or Greater Indirect Ownership Interest
Secretary Board of Directors		 Jan 1, 1998 10%
Corporate Officer
Secretary Board of Directors		 Jan 1, 1998
Connie Wooten
Individual 		5% Or Greater Indirect Ownership Interest Jan 1, 1998 10%
Corporate Officer
VP Board of Directors		 Aug 20, 2012 10%
Samuel Jordan
Individual 		5% Or Greater Indirect Ownership Interest Aug 26, 2010 10%
Corporate Officer
Board Member		 Aug 16, 2010 10%
Amanda O Dixon
Individual 		W-2 Managing Employee Mar 1, 2019
Kenneth Keith
Individual 		5% Or Greater Indirect Ownership Interest Nov 24, 2014 10%
Corporate Officer
Board Member		 Nov 24, 2014 10%

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Maple Hill Medical Center
Maple Hill, NC · CCN 341088		 Federally qualified health center 5% Or Greater Direct Ownership Interest Jan 6, 1975
Black River Family Practice
Burgaw, NC · CCN 341087		 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jan 6, 1975

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040324001267 NC Part B Supplier - Clinic/Group Practice 0345131579 Receives reassigned benefits from 17 practitioners
2 other NPIs on this enrollment
Practice locations: Maple Hill, NC; Burgaw, NC; Atkinson, NC
O20180502001033 NC Part a Provider - Federally Qualified Health Center (FQHC) 0345131579 Practice locations: Atkinson, NC

National Provider Directory

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 207R00000X
Federally Qualified Health Center (FQHC) 261QF0400X Yes
Rural Health Clinic/Center 261QR1300X
Family Nurse Practitioner
Group: 193200000X MULTI-SPECIALTY GROUP		 363LF0000X

Addresses

Primary practice location

109 W Church St
Atkinson, NC 28421-9230

Mailing address

301 S Campbell St
Burgaw, NC 28425-5011
Phone (910) 259-6973

Other identifiers

IdentifierTypeStateIssuer
343867ACMedicaidNC
03009OtherBCBS

Other names

  • Black River Health Center Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Dec 12, 2019.

{
    "created_epoch": "1128556800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1576108800000",
    "number": "1174511976",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "301 S CAMPBELL ST",
            "city": "BURGAW",
            "state": "NC",
            "postal_code": "284255011",
            "telephone_number": "910-259-6973",
            "fax_number": "910-259-6975"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "109 W CHURCH ST",
            "city": "ATKINSON",
            "state": "NC",
            "postal_code": "284219230",
            "telephone_number": "910-283-7783",
            "fax_number": "910-283-7927"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACK RIVER HEALTH SERVICES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-06",
        "last_updated": "2019-12-12",
        "certification_date": "2019-12-12",
        "status": "A",
        "authorized_official_last_name": "AMANN",
        "authorized_official_first_name": "LEE ANN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "910-259-6973"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "343867AC",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "03009",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Black River Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Black River Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Atkinson, NC

All providers in Atkinson, NC · Federally Qualified Health Center (FQHC) in North Carolina

Sources for this page

Verify at the official NPI Registry.