NPIMap

Organization Active NPI

Black River Health Services Inc

Doing business as Black River Health Center

  • Federally Qualified Health Center (FQHC)
  • Atkinson, NC
National Provider Identifier
1174511976
Registry record updated Dec 12, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BLACK RIVER HEALTH SERVICES INC
Doing business as
Black River Health Center
Practice address
109 W Church St
Atkinson, NC 28421-9230
Phone
(910) 283-7783
Fax
(910) 283-7927
NPI assigned
Oct 6, 2005
Last updated
Dec 12, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2019

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

Authorized official

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

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Rural Health Clinic/Center 261QR1300X
Family Nurse PractitionerGroup: 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 names 1

  • Black River Health Center Doing business as

Medicare participation

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

Enrollment records 2

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1174511976. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Apr 2, 1973 in NC
Enrollment address
109 W Church St
Atkinson, NC 28421-9230

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 2

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

National Provider Directory

National Provider Directory

Member of 1

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

Ownership & related parties

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 OfficerPresident Board of Directors Oct 24, 2008 10%
Ernie Johnson Individual 5% Or Greater Indirect Ownership InterestBoard Member Jul 25, 2011 10%
Corporate OfficerBoard Member Jul 25, 2011 10%
Caroleigh Sholar Individual 5% Or Greater Indirect Ownership Interest Jan 26, 1998 10%
Corporate OfficerBoard Member Jan 26, 1998 10%
Lorie Floyd Individual 5% Or Greater Indirect Ownership Interest Sep 26, 2014 10%
Corporate OfficerBoard Member Sep 29, 2014 10%
Lee Ann Amann Individual Corporate OfficerCeo Jun 16, 2015
Corporate DirectorCeo Jun 16, 2015
W-2 Managing EmployeeCeo Jun 16, 2015
Judy Blanchard Individual 5% Or Greater Indirect Ownership Interest Jan 17, 2011 10%
Corporate OfficerBoard Member Jan 17, 2011 10%
Edward Brown Individual Corporate OfficerTreasurer Board of Directors Jun 27, 2014 10%
Sandra Rooks Individual 5% Or Greater Indirect Ownership InterestSecretary Board of Directors Jan 1, 1998 10%
Corporate OfficerSecretary Board of Directors Jan 1, 1998
Connie Wooten Individual 5% Or Greater Indirect Ownership Interest Jan 1, 1998 10%
Corporate OfficerVP Board of Directors Aug 20, 2012 10%
Samuel Jordan Individual 5% Or Greater Indirect Ownership Interest Aug 26, 2010 10%
Corporate OfficerBoard 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 OfficerBoard 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 CenterMaple Hill, NC, CCN 341088 Federally qualified health center 5% Or Greater Direct Ownership Interest Jan 6, 1975
Black River Family PracticeBurgaw, NC, CCN 341087 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jan 6, 1975

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 17

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.

View all 17

NPI Registry JSON

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

{
    "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": [],
    "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

Sources for this page

Verify at the official NPI Registry.