Provider Demographics
NPI:1407948854
Name:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Other - Org Name:HENRY FORD ALLEGIANCE ADDICTION RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP FINANCE/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-841-6979
Mailing Address - Street 1:205 N. EAST AVE
Mailing Address - Street 2:7TH FL ONE JACKSON SQUARE
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201
Mailing Address - Country:US
Mailing Address - Phone:517-788-4713
Mailing Address - Fax:517-841-7419
Practice Address - Street 1:205 N. EAST AVE
Practice Address - Street 2:7TH FL ONE JACKSON SQUARE
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201
Practice Address - Country:US
Practice Address - Phone:517-788-4713
Practice Address - Fax:517-841-7419
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-29
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI045908OtherHEALTH ALLIANCE PLAN
MI100094OtherPREFERRED CHOICES
MIHL380002OtherMCARE
FL092063100Medicaid
MI030066700OtherUNITED MINE WORKERS
OH2855754Medicaid
MI00080OtherBLUE CARE NETWORK
KY01410125Medicaid
MIP100094OtherPREFERRED CARE CHOICES
MI20080OtherBLUE CROSS OF MICHIGAN
MI5020010OtherPHYSICIAN'S HEALTH PLAN
KY01410125Medicaid
MI=========10OtherTRICARE CHAMPUS