Healthcare Provider Details

I. General information

NPI: 1124265236
Provider Name (Legal Business Name): WAKE FOREST HEALTH NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 KINDERTON BLVD
BERMUDA RUN NC
27006-7302
US

IV. Provider business mailing address

114 KINDERTON BLVD
BERMUDA RUN NC
27006-7302
US

V. Phone/Fax

Practice location:
  • Phone: 336-998-9742
  • Fax: 336-998-9410
Mailing address:
  • Phone: 336-998-9742
  • Fax: 336-998-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CRAIG MICHAEL GREVEN
Title or Position: SR VP CLINICAL OPERATIONS
Credential:
Phone: 336-716-1331