NPIMap

Black River Health Services Inc

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

NPI 1356339154 · NPPES record last updated Jan 21, 2020

Key facts

NPI
1356339154
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
BLACK RIVER HEALTH SERVICES INC
Practice address
4811 NC Highway 50
Maple Hill, NC 28454-8153
Phone
(910) 259-6444
Fax
(910) 259-6659
NPI assigned
Oct 6, 2005
Organization subpart
No

Authorized official

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

Owners & managing parties with NPI records 3

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

Owned or controlled facilities with NPI records 1

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.

Facilities with the same owner 1

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

Practitioners 10

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 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
Corporation · Non-profit
Incorporated
Apr 2, 1973 in NC
Enrollment address
4811 NC Highway 50
Maple Hill, NC 28454-8153

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 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%
Lee Ann Amann
Individual 		Corporate Officer
Ceo		 Jun 16, 2015
Corporate Director
Ceo		 Jun 16, 2015
W-2 Managing Employee
Ceo		 Jun 16, 2015
Edward Brown
Individual 		5% Or Greater Indirect Ownership Interest Jul 2, 2005 10%
Corporate Officer
Treasurer, Board of Directors		 Jun 27, 2014 10%
Connie Wooten
Individual 		5% Or Greater Indirect Ownership Interest Jan 1, 1998 10%
Corporate Officer
Vice President		 Aug 20, 2012 10%
Samuel Jordan
Individual 		5% Or Greater Indirect Ownership Interest Aug 16, 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 1

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

FacilityTypeRoleSince
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
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

National Provider Directory

Specialties & licenses

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

IdentifierTypeStateIssuer
344622ACMedicaidNC
0176JOtherBCBS

Other names

  • Maple Hill Medical Center Doing business as

Other providers in Maple Hill, NC

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

Sources for this page

Verify at the official NPI Registry.