NPIMap

Organization Active NPI

Black River Health Services Inc

Doing business as Maple Hill Medical Center

  • Federally Qualified Health Center (FQHC)
  • Maple Hill, NC
National Provider Identifier
1356339154
Registry record updated Jan 21, 2020
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
Maple Hill Medical Center
Practice address
4811 NC Highway 50
Maple Hill, NC 28454-8153
Phone
(910) 259-6444
Fax
(910) 259-6659
NPI assigned
Oct 6, 2005
Last updated
Jan 21, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 21, 2020

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

Authorized official

Name
Leeann Amann
Title
Administrator
Phone
(910) 259-6973

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Primary Care Clinic/Center 261QP2300X
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

4811 NC Highway 50
Maple Hill, NC 28454-8153

Mailing address

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

Other names 1

  • Maple Hill Medical 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
This NPI is an additional NPI on the enrollment
Practice locations: Maple Hill, NC; Burgaw, NC; Atkinson, NC
O20180420000833 NC Part A Provider - Federally Qualified Health Center (FQHC) 0345131579 Practice locations: Maple Hill, NC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356339154. Details of each certification follow.

Federally qualified health center certification: CCN 341088

Legal name
BLACK RIVER HEALTH SERVICES INC
Doing business as
MAPLE HILL MEDICAL 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
4811 NC Highway 50
Maple Hill, NC 28454-8153

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.

Locations

301 S Campbell St
Burgaw, NC 28425
Phone (910) 259-5721

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Black River Health Services Inc Organization, Maple Hill, NC Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 6, 1975
Ernie Johnson Individual 5% Or Greater Indirect Ownership Interest 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%
Lee Ann Amann Individual Corporate OfficerCeo Jun 16, 2015
Corporate DirectorCeo Jun 16, 2015
W-2 Managing EmployeeCeo Jun 16, 2015
Edward Brown Individual 5% Or Greater Indirect Ownership Interest Jul 2, 2005 10%
Corporate OfficerTreasurer, Board of Directors Jun 27, 2014 10%
Connie Wooten Individual 5% Or Greater Indirect Ownership Interest Jan 1, 1998 10%
Corporate OfficerVice President Aug 20, 2012 10%
Samuel Jordan Individual 5% Or Greater Indirect Ownership Interest Aug 16, 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%

Owners & managing parties with NPI records 3

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
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 1

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

Facilities with the same owner 1

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

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": "1128556800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1579564800000",
    "number": "1356339154",
    "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": "4811 NC HIGHWAY 50",
            "city": "MAPLE HILL",
            "state": "NC",
            "postal_code": "284548153",
            "telephone_number": "910-259-6444",
            "fax_number": "910-259-6659"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACK RIVER HEALTH SERVICES INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-06",
        "last_updated": "2020-01-21",
        "certification_date": "2020-01-21",
        "status": "A",
        "authorized_official_last_name": "AMANN",
        "authorized_official_first_name": "LEEANN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "910-259-6973"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Maple Hill Medical Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Maple Hill Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Maple Hill, NC

Sources for this page

Verify at the official NPI Registry.