Provider Demographics
NPI:1639684137
Name:W A FOOTE MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:W A FOOTE MEMORIAL HOSPITAL INC
Other - Org Name:HFAH FREE STANDING CLINIC
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:517-205-7410
Mailing Address - Street 1:PO BOX 67000 DEPT 272801
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-205-7843
Mailing Address - Fax:517-205-7419
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4922
Practice Address - Fax:517-205-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106000004163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1053403402Medicaid