Provider Demographics
NPI:1659495133
Name:WAKE FOREST HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK LLC
Other - Org Name:ATRIUM HEALTH WAKE FOREST BAPTIST INTERNAL MEDICINE - PREMIER
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 1:4515 PREMIER DRIVE
Practice Address - Street 2:SUITE 204
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8350
Practice Address - Country:US
Practice Address - Phone:336-802-2075
Practice Address - Fax:336-802-2076
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
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22810OtherMEDCOST
NCCC4241OtherRR MEDICARE
NCCD6614OtherRR MEDICARE
NC0246TOtherBCBS
NC5913200Medicaid
NCD266OtherPARTNERS
NC7780730OtherAETNA
NCCB8658OtherRR MEDICARE
NCCC4243OtherRR MEDICARE
NC1212660007OtherDME
NC890246TMedicaid
NCCC4243OtherRR MEDICARE
NC890246TMedicaid