Provider Demographics
NPI:1104959055
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:MD
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:
Practice Address - Street 1:1565 N UNIVERSITY PARKWAY
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7612
Practice Address - Country:US
Practice Address - Phone:336-802-2020
Practice Address - Fax:336-802-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890246JMedicaid
NC22797OtherMEDCOST
NCCD6614OtherRR MEDICARE
NC1212660016OtherDME
NCCC4243OtherRR MEDICARE
NCCB8658OtherRR MEDICARE
NC7719721OtherAETNA
NC=========OtherTRICARE
NCD266OtherPARTNERS
NC0246JOtherBCBS
NCCC4241OtherRR MEDICARE
NC7719721OtherAETNA
NCCC4243OtherRR MEDICARE
NCCC4241OtherRR MEDICARE