Provider Demographics
NPI:1669569034
Name:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:700 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1626
Mailing Address - Country:US
Mailing Address - Phone:517-768-8873
Mailing Address - Fax:517-780-3816
Practice Address - Street 1:700 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1626
Practice Address - Country:US
Practice Address - Phone:517-768-8873
Practice Address - Fax:517-780-3816
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:W A FOOTE MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-06
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI380010332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540C811250OtherBLUE CROSS OF MICHIGAN
MI540C800660OtherBLUE CROSS OF MICHIGAN
MI468131387Medicaid
MI82-20024OtherPHYSICIAN'S HEALTH PLAN
MI468131387Medicaid