Provider Demographics
NPI:1134666092
Name:W.A. FOOTE MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:W.A. FOOTE MEMORIAL HOSPITAL, INC
Other - Org Name:HENRY FORD ALLEGIANCE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP
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:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267
Mailing Address - Country:US
Mailing Address - Phone:517-205-7843
Mailing Address - Fax:517-205-7419
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
Practice Address - Country:US
Practice Address - Phone:517-205-7843
Practice Address - Fax:517-841-7419
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HENRY FORD ALLEGIANCE HEALTH GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-30
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000044101Y00000X, 104100000X
101YM0800X, 101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1326078866Medicaid
MI1326078866Medicaid