Provider Demographics
NPI:1366988347
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:SVP, CMO, CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
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:517-205-7843
Mailing Address - Fax:517-841-7419
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
Practice Address - Country:US
Practice Address - Phone:517-205-7843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLEGIANCE HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-13
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LP0808X, 363LW0102X, 367A00000X, 363LA2100X, 363LA2200X, 363LF0000X, 363LG0600X, 363LP0200X
MI1060000044363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629000708Medicaid
MI0N48080Medicare PIN