Provider Demographics
NPI:1275658692
Name:WAKE FOREST HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK LLC
Other - Org Name:ATRIUM HEALTH WAKE FOREST BAPTIST HIGH POINT FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP CLINICAL OPERATION 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:336-716-3202
Practice Address - Street 1:905 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7075
Practice Address - Country:US
Practice Address - Phone:336-802-2040
Practice Address - Fax:336-802-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD266OtherPARTNERS MEDICARE CHOICE
269374OtherMAMSI
NCCC6608OtherRR MEDICARE
NCCC4242OtherRR MEDICARE
80024OtherMEDCOST
NCCC4243OtherRR MEDICARE
NC890246WMedicaid
NCCD6614OtherRR MEDICARE
NCCC4241OtherRR MEDICARE
7338741OtherAETNA
NCCC5472OtherRR MEDICARE
0246WOtherBCBS
NCCB8658OtherRRMC
NCCF9200OtherRR MEDICARE
NCCC6608OtherRR MEDICARE
7338741OtherAETNA
NCCC4243OtherRR MEDICARE
NC890246WMedicaid