Provider Demographics
NPI:1174644058
Name:WA FOOTE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WA FOOTE MEMORIAL HOSPITAL
Other - Org Name:ON HOLD
Other - Org Type:Other Name
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:CFO
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:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-6913
Mailing Address - Fax:517-841-6917
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:517-788-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WA FOOTE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-02
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X, 207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty