Provider Demographics
NPI:1265806343
Name:WA FOOTE MEMORIAL HOSPITAL INC.
Entity type:Organization
Organization Name:WA FOOTE MEMORIAL HOSPITAL INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP FINANCE/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE'
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-841-6979
Mailing Address - Street 1:760 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2048
Mailing Address - Country:US
Mailing Address - Phone:517-205-2700
Mailing Address - Fax:517-205-2720
Practice Address - Street 1:760 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2048
Practice Address - Country:US
Practice Address - Phone:517-205-2700
Practice Address - Fax:517-205-2720
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WA FOOTE MEMORIAL HOSPITAL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-30
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI9604Medicare PIN