Provider Demographics
NPI:1073955050
Name:WA FOOTE MEMORIAL HOSPITAL INC.
Entity Type:Organization
Organization Name:WA FOOTE MEMORIAL HOSPITAL INC.
Other - Org Name:HENRY FORD ALLEGIANCE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP. CMO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-205-6407
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-841-7482
Mailing Address - Fax:517-841-7476
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-841-7878
Practice Address - Fax:517-817-7664
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WA FOOTE MEMOIRAL HOSPITAL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-19
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI7230Medicare PIN