=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306174982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WA FOOTE MEMORIAL HOSPITAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2009
-----------------------------------------------------
Last Update Date | 04/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 E MICHIGAN AVE SUITE 110
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-1852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-817-7638
-----------------------------------------------------
Fax | 517-817-7636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 E MICHIGAN AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-768-8873
-----------------------------------------------------
Fax | 517-780-3816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. VICE PRESIDENT, FINANCE CFO
-----------------------------------------------------
Name | JEANNE' WICKENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-788-6979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 380010
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------