NPIMap

Organization Active NPI

Tri County Community Health Council Inc

  • Federally Qualified Health Center (FQHC)
  • Smithfield, NC
National Provider Identifier
1407039324
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
507 N Brightleaf Blvd
Suite 209
Smithfield, NC 27577-4405
Phone
(877) 935-5255
Fax
(910) 236-2118
NPI assigned
Dec 13, 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

507 N Brightleaf Blvd
Suite 209
Smithfield, NC 27577-4405

Mailing address

PO Box 340
Four Oaks, NC 27524-0340
Phone (910) 957-6194

Other identifiers 1

IdentifierTypeStateIssuer
341928OtherNCMEDICARE OSCAR

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…
O20080411000610 NC Part A Provider - Federally Qualified Health Center (FQHC) 2163409558 Practice locations: Smithfield, NC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407039324. Details of each certification follow.

Federally qualified health center certification: CCN 341928

Legal name
TRI COUNTY COMMUNITY HEALTH COUNCIL INC
Doing business as
COMMWELL HEALTH OF SMITHFIELD
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 19, 2008
Last certification
May 19, 2008
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
507 N Brightleaf Blvd
Ste 209
Smithfield, NC 27577-4405

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 Health30 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

Locations

507 N Brightleaf Blvd
Ste 209
Smithfield, NC 27577
Phone (919) 934-0850

Ownership & related parties

All disclosed owners & managing parties 15

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 OfficerBoard Member Nov 17, 2005
Phillip E Mills Individual Corporate OfficerBoard Member Jul 22, 2004
Vanessa a Burgess Individual Corporate OfficerBoard Member Jul 26, 1991
Raymond Lindsey Individual Corporate OfficerBoard Member Oct 14, 2010
Kenneth a Cabral Individual Corporate DirectorBoard of Directors Apr 16, 2015
Nathan J Tilghman Individual Corporate OfficerChairman Jun 20, 1994
Mary Crumpler Individual Corporate DirectorBoard of Directors Mar 17, 2015
Silvia a. Cendejas Individual Corporate DirectorBoard of Directors Dec 15, 2011
Gary Herring Individual Corporate DirectorBoard of Directors Mar 17, 2016
Spencer McAlpine Individual Corporate DirectorBoard of Directors Aug 29, 2013
William Taylor Individual Corporate DirectorBoard of Directors May 18, 2017
Jose Garcia Individual Corporate OfficerDirector Aug 1, 2019
Pamela Tripp Individual Corporate OfficerCeo Sep 21, 2009
Corporate DirectorCeo Oct 1, 2005
W-2 Managing EmployeeCeo Sep 21, 2009 100%
Mary E Blaizes Individual Corporate OfficerSecretary Jul 17, 1997
William C Ellison Individual Corporate DirectorSr. Director of Revenue Cycle Mar 1, 2022

Practitioners & affiliated clinicians

Practitioners 3

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": "1197504000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1711497600000",
    "number": "1407039324",
    "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": "910-957-6194",
            "fax_number": "910-567-5342"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "507 N BRIGHTLEAF BLVD",
            "address_2": "SUITE 209",
            "city": "SMITHFIELD",
            "state": "NC",
            "postal_code": "275774405",
            "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": "2007-12-13",
        "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": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE OSCAR",
            "identifier": "341928",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Smithfield, NC

Sources for this page

Verify at the official NPI Registry.