Provider Demographics
NPI:1700901436
Name:WAKE FOREST HEALTH NETWORK, LLC
Entity Type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK, LLC
Other - Org Name:ATRIUM HEALTH WAKE FOREST BAPTIST FAMILY 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 DR
Practice Address - Street 2:SUITE 201
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8357
Practice Address - Country:US
Practice Address - Phone:336-802-2610
Practice Address - Fax:336-802-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCC4241OtherRR MEDICARE
NC269374OtherMAMSI
NC0246KOtherBCBS
NCD266OtherPARTNERS MEDICARE CHOICE
NC1212660012OtherDME
NC890246KMedicaid
NC7446746OtherAETNA
NCCB8658OtherRRMC GROUP
NCCC4243OtherRR MEDICARE
NCCD6614OtherRR MEDICARE
NC50132OtherMEDCOST
NCCC4243OtherRR MEDICARE
=========-004OtherTRICARE
NC1212660012Medicare NSC
NC2318873IMedicare PIN