Provider Demographics
NPI:1326078866
Name:WA FOOTE MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:WA FOOTE MEMORIAL HOSPITAL, INC
Other - Org Name: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:517-788-4883
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, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-03
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YP2500X, 261QM0801X
103T00000X, 104100000X, 2084N0400X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
260C863890OtherBCBSM
MI750910501OtherBCBSM
MI680C810300OtherBCBSM
MICC5829OtherRR MEDICARE
MI800C810270OtherBCBSM
MI0M12270Medicare Oscar/Certification
260C863890OtherBCBSM
MICC5829OtherRR MEDICARE