1700918877 NPI number — WAKE FOREST HEALTH NETWORK LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700918877 NPI number — WAKE FOREST HEALTH NETWORK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE FOREST HEALTH NETWORK LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ATRIUM HEALTH WAKE FOREST BAPTIST NEUROLOGY - TRIAD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700918877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 KIMEL FOREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-6074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-716-1331
Provider Business Mailing Address Fax Number:
336-716-3202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 KIMEL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-6983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-768-6347
Provider Business Practice Location Address Fax Number:
336-760-9393
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOWERTON
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
MARS
Authorized Official Title or Position:
SR VP NETWORK PHYS & HS CMO
Authorized Official Telephone Number:
336-716-1331

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CC4241 . This is a "RRMC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC4242 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC5472 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: D266 . This is a "PARTNERS MEDICARE CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 016UW . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC4243 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CF9200 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 269374 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: B0433 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".
  • Identifier: CB8658 . This is a "RRMC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CD6614 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89016UW , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CC6608 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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