1639575400 NPI number — WAKE FOREST HEALTH NETWORK LLC

Table of content: (NPI 1639575400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639575400 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:
1639575400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2023
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:
223 W. WARD ST. STE. B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27203-5611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-625-4215
Provider Business Practice Location Address Fax Number:
336-626-0919
Provider Enumeration Date:
11/06/2014

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: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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