Provider Demographics
NPI:1063453553
Name:WAKE FOREST HEALTH NETWORK, LLC
Entity type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP NETWORK PHYS & HS CMO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:MARS
Authorized Official - Last Name:HOWERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-716-1331
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:336-716-1331
Practice Address - Street 1:1814 WESTCHESTER DR
Practice Address - Street 2:SUITE 400
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7010
Practice Address - Country:US
Practice Address - Phone:336-802-2130
Practice Address - Fax:336-802-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207W00000X, 207Q00000X, 207RP1001X, 207V00000X, 207X00000X, 207Y00000X, 208000000X, 2084N0400X, 208600000X, 208800000X, 208M00000X, 208800000X, 208M00000X, 207Q00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCC5472OtherRAILROAD MEDICARE
NCCC4241OtherRAILROAD MEDICARE
NCCC4242OtherRAILROAD MEDICARE
NCCC6608OtherRAILROAD MEDICARE
NC7001156Medicaid
NCCB8658OtherRAILROAD MEDICARE
NCCD6614OtherRAILROAD MEDICARE
NCCF9200OtherRAILROAD MEDICARE
NCCC4243OtherRAILROAD MEDICARE
NCCC5472OtherRAILROAD MEDICARE
NC2552440Medicare PIN