Provider Demographics
NPI:1407393366
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:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-841-7843
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:517-841-7843
Mailing Address - Fax:517-841-7419
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:517-841-7843
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:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000044208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1760437826Medicaid
MI1760437826Medicaid