Provider Demographics
NPI:1013031301
Name:WAKE FOREST HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK LLC
Other - Org Name:ATRIUM HEALTH WAKE FOREST BAPTIST WOMEN'S IMAGING CENTER
Other - Org Type:Doing Business As
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:336-716-3202
Practice Address - Street 1:1814 WESTCHESTER DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7369
Practice Address - Country:US
Practice Address - Phone:336-802-2185
Practice Address - Fax:336-802-2186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0275QOtherBCBS
NCCC4243OtherRR MEDICARE
23180OtherMEDCOST
7262737OtherAETNA
NCCC4242OtherRR MEDICARE
NCCD6614OtherRRMC
NCCF9200OtherRRMC
NC89012U2Medicaid
NCCB8658OtherRRMC
NCCC4241OtherRR MEDICARE
NCCC6608OtherRR MEDICARE
271662OtherMAMSI
NC89012U1Medicaid
NCCC5472OtherRRMC
NCD266OtherPARTNERS MEDICARE CHOICE
NCCC4242OtherRR MEDICARE
NC2318873Medicare PIN