MEDICARE: W.A. FOOTE MEMORIAL HOSPITAL, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician	1060000044	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598202459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W.A. FOOTE MEMORIAL HOSPITAL, INC

Provider Business Mailing Address
First Line	:	PO BOX 670884
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48267-0884
Country	:	US
Telephone Number	:	800-999-5829
Fax Number	:	313-876-1305

Provider Business Practice Location Address
First Line	:	205 N. EAST AVE
Second Line	:	ATTN: PROVIDER ENROLLMENT
City	:	JACKSON
State	:	MI
Zip	:	49201
Country	:	US
Telephone Number	:	517-841-7843
Fax Number	:	517-841-7419

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KIMBERLY CEBALT
Credential	:
Telephone Number	:	313-874-6764

Provider Enumeration Date	:	01/30/2017
Last Update Date	:	01/21/2026

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