Healthcare Provider Details

I. General information

NPI: 1265487722
Provider Name (Legal Business Name): WA FOOTE MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

DEPARTMENT 272801 PO BOX 67000
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 Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: JEANNE' WICKENS
Title or Position: SENIOR VICE PRESIDENT OF FINANCE
Credential: CFO
Phone: 517-841-6979