Healthcare Provider Details

I. General information

NPI: 1699212803
Provider Name (Legal Business Name): W.A. FOOTE MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N. EAST AVE ATTN: PROVIDER ENROLLMENT
JACKSON MI
49201
US

IV. Provider business mailing address

PO BOX 67000 DEPARTMENT 272801
DETROIT MI
48267
US

V. Phone/Fax

Practice location:
  • Phone: 517-841-7843
  • Fax: 517-841-7419
Mailing address:
  • Phone: 517-841-7843
  • Fax: 517-841-7419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1060000044
License Number StateMI

VIII. Authorized Official

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