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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1861996753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W. A. FOOTE MEMORIAL HOSPITAL, INC

Provider Business Mailing Address
First Line	:	PO BOX 67000 DEPT 272801
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48267-0001
Country	:	US
Telephone Number	:	517-205-7843
Fax Number	:	517-205-7419

Provider Business Practice Location Address
First Line	:	12369 E MICHIGAN AVE
Second Line	:
City	:	GRASS LAKE
State	:	MI
Zip	:	49240-9213
Country	:	US
Telephone Number	:	517-205-2539
Fax Number	:	517-205-0105

Authorized Official
Title or Position	:	VP FINANCE
Name	:	KEVIN LEONARD
Credential	:
Telephone Number	:	517-205-7843

Provider Enumeration Date	:	03/23/2018
Last Update Date	:	03/23/2018

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