=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598857948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W.A. FOOTE MEMORIAL HOSPITAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 03/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 N. EAST AVE 7TH FL ONE JACKSON SQUARE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-788-4713
-----------------------------------------------------
Fax | 517-841-7419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 N. EAST AVE 7TH FL ONE JACKSON SQUARE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-788-4713
-----------------------------------------------------
Fax | 517-841-7419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP, CMO
-----------------------------------------------------
Name | MRS. MARK SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-205-6407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 276400000X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------