Provider Demographics
NPI:1265487722
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:SENIOR VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE'
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:517-841-6979
Mailing Address - Street 1:DEPARTMENT 272801
Mailing Address - Street 2:PO BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
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:517-788-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WA FOOTE MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICC5829OtherRR MEDICARE
MI700C810330OtherBCBSM DOCTORS
MI700C810330OtherBCBSM DOCTORS
MI0N79450Medicare PIN