MEDICARE: BLACK RIVER HEALTH SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician
3	261QR1300X	Rural Health Clinic/Center
4	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0104X	OTHER		BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093703886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK RIVER HEALTH SERVICES INC

Provider Business Mailing Address
First Line	:	301 S CAMPBELL ST
Second Line	:
City	:	BURGAW
State	:	NC
Zip	:	28425-5011
Country	:	US
Telephone Number	:	910-259-6973
Fax Number	:	910-259-6975

Provider Business Practice Location Address
First Line	:	301 S CAMPBELL ST
Second Line	:
City	:	BURGAW
State	:	NC
Zip	:	28425-5011
Country	:	US
Telephone Number	:	910-259-5721
Fax Number	:	910-259-8002

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LEE ANN AMANN
Credential	:
Telephone Number	:	910-259-6973

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	12/12/2019

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Directions to “BLACK RIVER HEALTH SERVICES INC ” Practice Location

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