=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124265236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAKE FOREST HEALTH NETWORK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2009
-----------------------------------------------------
Last Update Date | 09/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 KINDERTON BLVD
-----------------------------------------------------
City | BERMUDA RUN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27006-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-998-9742
-----------------------------------------------------
Fax | 336-998-9410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 KINDERTON BLVD
-----------------------------------------------------
City | BERMUDA RUN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27006-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-998-9742
-----------------------------------------------------
Fax | 336-998-9410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR VP CLINICAL OPERATIONS
-----------------------------------------------------
Name | CRAIG MICHAEL GREVEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-716-1331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------