Basic Information
| Provider Information | |||||||||
| NPI: | 1063647394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKE FOREST HEALTH NETWORK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FORD, SIMPSON, LIVELY & RICE PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KIMEL FOREST DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367161331 | ||||||||
| FaxNumber: | 3367163202 | ||||||||
| Practice Location | |||||||||
| Address1: | 2933 MAPLEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271034009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367943380 | ||||||||
| FaxNumber: | 3367943378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | HOWERTON | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | MARS | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP NETWORK PHYS & HS CMO | ||||||||
| AuthorizedOfficialTelephone: | 3367161331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5909124 | 05 | NC | MEDICAID | 5950113 | 05 | NC | MEDICAID | 5950112 | 05 | NC | MEDICAID |