Provider Demographics
NPI:1023142122
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:336-716-3202
Practice Address - Street 1:1665 WESTBROOK PLAZA DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2993
Practice Address - Country:US
Practice Address - Phone:336-760-8380
Practice Address - Fax:336-760-8388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCC4242OtherRAILROAD MEDICARE
NC5905774Medicaid
NCCC5472OtherRAILROAD MEDICARE
NCD266OtherPARTNERS MEDICARE CHOICE
98096OtherMEDCOST
NCCB8658OtherRAILROAD MEDICARE
NCCC6608OtherRAILROAD MEDICARE
0007312143OtherAETNA
NC018PHOtherBCBS
269374OtherMAMSI
NCCC4243OtherRAILROAD MEDICARE
NCCD6614OtherRAILROAD MEDICARE
NCCF9200OtherRAILROAD MEDICARE
NCCC4241OtherRAILROAD MEDICARE
NCCC4241OtherRAILROAD MEDICARE
NCCC6608OtherRAILROAD MEDICARE