Basic Information
| Provider Information | |||||||||
| NPI: | 1003803032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 344 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271020344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | HIGH | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, HEALTH SYSTEM, WFBH | ||||||||
| AuthorizedOfficialTelephone: | 3367168021 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD, MS | ||||||||
| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 07001 | 01 | NC | BCBS | OTHER | 89013KW | 05 | NC | MEDICAID | 2433646 | 01 | NC | MCARE GROUP NUMBER - PODI | OTHER | C08811 | 01 | VA | MCARE GROUP - VIRGINIA ME | OTHER |