Healthcare Provider Details

I. General information

NPI: 1831123728
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: 03/06/2024
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 67000 DEPARTMENT 272801
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4800
  • Fax:
Mailing address:
  • Phone: 517-841-7482
  • Fax: 517-841-7476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMI

VIII. Authorized Official

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