Provider Demographics
NPI:1013101781
Name:BLACK RIVER HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:BLACK RIVER HEALTH SERVICES, INC.
Other - Org Name:BLACK RIVER FAMILY PRACTICE AT ROCKY POINT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-259-6973
Mailing Address - Street 1:301 S CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-5011
Mailing Address - Country:US
Mailing Address - Phone:910-259-6973
Mailing Address - Fax:910-259-6975
Practice Address - Street 1:7910 US HIGHWAY 117 S
Practice Address - Street 2:SUITE 120
Practice Address - City:ROCKY POINT
Practice Address - State:NC
Practice Address - Zip Code:28457-7409
Practice Address - Country:US
Practice Address - Phone:910-675-0120
Practice Address - Fax:910-675-2308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908417Medicaid
NC020A0OtherBCBS NC
NC=========OtherEIN
NC2804303CMedicare PIN