Provider Demographics
NPI:1700918877
Name:WAKE FOREST HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK LLC
Other - Org Name:ATRIUM HEALTH WAKE FOREST BAPTIST NEUROLOGY - TRIAD
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 1:145 KIMEL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6983
Practice Address - Country:US
Practice Address - Phone:336-768-6347
Practice Address - Fax:336-760-9393
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST HEALTH NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-12
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCC4241OtherRRMC
NCCC4242OtherRR MEDICARE
NCCC5472OtherRR MEDICARE
NCD266OtherPARTNERS MEDICARE CHOICE
NC016UWOtherBCBS
NCCC4243OtherRR MEDICARE
NCCF9200OtherRR MEDICARE
269374OtherMAMSI
B0433OtherMEDCOST
NCCB8658OtherRRMC
NCCD6614OtherRR MEDICARE
NC89016UWMedicaid
NCCC6608OtherRR MEDICARE
NCCD6614OtherRR MEDICARE
NCCC4243OtherRR MEDICARE