Provider Demographics
NPI:1598776718
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:SVP, CMO, CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-205-6407
Mailing Address - Street 1:PO BOX 64000
Mailing Address - Street 2:DRAWER 641535
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48264-0001
Mailing Address - Country:US
Mailing Address - Phone:517-788-4800
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:CRNA
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:2006-08-11
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOC86048Medicare ID - Type Unspecified