Healthcare Provider Details

I. General information

NPI: 1770858938
Provider Name (Legal Business Name): WAKE FOREST HEALTH NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE TRADE STREET
GRANITE FALLS NC
28630-1525
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 828-396-3136
  • Fax: 828-396-3105
Mailing address:
  • Phone: 336-716-1331
  • Fax: 336-716-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL MARS HOWERTON
Title or Position: SR VP NETWORK PHYS & HS CMO
Credential:
Phone: 336-716-1331