Provider Demographics
NPI:1871685222
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: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
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP100094OtherPREFERRED CARE CHOICES
OH2855754Medicaid
FL092063100Medicaid
MI100094OtherPREFERRED CHOICES
MI100442Medicaid
MI405172240Medicaid
MI045908OtherHEALTH ALLIANCE PLAN
MIHL380002OtherMCARE
MI00080OtherBLUE CROSS OF MICHIGAN
KY01410125Medicaid
MI030066700OtherUNITED MINE WORKERS
MI5020010OtherPHYSICIAN'S HEALTH PLAN
MI230092Medicare PIN