Basic Information
| Provider Information | |||||||||
| NPI: | 1053403402 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | W.A. FOOTE MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HENRY FORD ALLEGIANCE HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884800 | ||||||||
| FaxNumber: | 5177966450 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172054800 | ||||||||
| FaxNumber: | 5172057419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP - CMO, CEO - HFAMG | ||||||||
| AuthorizedOfficialTelephone: | 5172056407 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 030066700 | 01 | MA | UNITED MINE WORKERS | OTHER | HL380002 | 01 | MI | MCARE | OTHER | 00080 | 01 | MI | BLUE CARE NETWORK | OTHER | 00080 | 01 | MI | BLUE CROSS OF MICHIGAN | OTHER | 100442 | 05 | MI | MEDICAID | P100094 | 01 | MI | PREFERRED CARE CHOICES | OTHER | 301556349 | 05 | MI | MEDICAID | 5020010 | 01 | MI | PHYSICIAN'S HEALTH PLAN | OTHER | 100094 | 01 | MI | PREFERRED CHOICES | OTHER | 045908 | 01 | MI | HEALTH ALLIANCE PLAN | OTHER |