Provider Demographics
NPI:1295850923
Name:WAKE FOREST HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK LLC
Other - Org Name:ATRIUM HEALTH WAKE FOREST BAPTIST GASTROENTEROLOGY - HIGH POINT
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 DR STE 101
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7369
Practice Address - Country:US
Practice Address - Phone:336-802-2105
Practice Address - Fax:336-802-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7640710OtherAETNA
50146OtherMEDCOST
NC0247NOtherBCBS
NCCD6614OtherRR MEDICARE
NC5913176Medicaid
NCCB8658OtherRR MEDICARE
NCCC4242OtherRR MEDICARE
NCCC5472OtherRR MEDICARE
NCCF9200OtherRR MEDICARE
NC890247NMedicaid
NCD266OtherPARTNERS MEDICARE CHOICE
NCCC4243OtherRR MEDICARE
NCCC6608OtherRR MEDICARE
269374OtherMAMSI
NCCC4241OtherRRMC
50146OtherMEDCOST
NC5913176Medicaid
50146OtherMEDCOST