1063453553 NPI number — WAKE FOREST HEALTH NETWORK, LLC

Table of content: (NPI 1063453553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063453553 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:
Provider Other Organization Name Type Code:
6
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:
1063453553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2021
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:
336-716-1331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1814 WESTCHESTER DR
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27262-7010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-802-2130
Provider Business Practice Location Address Fax Number:
336-802-2131
Provider Enumeration Date:
06/08/2006

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: 207Q00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CC5472 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC4241 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC4242 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC6608 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7001156 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB8658 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CD6614 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CF9200 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC4243 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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