Provider Demographics
NPI:1184951634
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 1:306 WESTWOOD AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4342
Practice Address - Country:US
Practice Address - Phone:336-885-0149
Practice Address - Fax:336-885-0101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST HEALTH NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-04
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913500Medicaid
NC5913663Medicaid
NC2318873Medicare PIN