Provider Demographics
NPI:1053175299
Name:WAKE FOREST HEALTH NETWORK, LLC
Entity type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GREVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-716-1331
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:
Practice Address - Street 1:4529 JESSUP GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9407
Practice Address - Country:US
Practice Address - Phone:336-605-0190
Practice Address - Fax:336-605-0930
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAKE FOREST HEALTH NETWORK, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-08
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty