Healthcare Provider Details

I. General information

NPI: 1073547964
Provider Name (Legal Business Name): WA FOOTE MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

PO BOX 67000 DEPARTMENT 272801
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4800
  • Fax:
Mailing address:
  • Phone: 517-841-6913
  • Fax: 517-841-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: MARK SMITH
Title or Position: SVP - CMO, CEO HFAMG EXECUTIVE
Credential: CFO
Phone: 517-205-6407