Provider Demographics
NPI:1336165455
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 - HFAMG
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-205-6407
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:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-788-4800
Mailing Address - Fax:517-841-6917
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:517-788-4800
Practice Address - Fax:517-841-6917
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WA FOOTE MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-14
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty