Healthcare Provider Details

I. General information

NPI: 1962953034
Provider Name (Legal Business Name): WA FOOTE MEMORIAL HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
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 64787 # 64000
DETROIT MI
48264-0001
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7843
  • Fax:
Mailing address:
  • Phone: 517-205-7843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1060000044
License Number StateMI

VIII. Authorized Official

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