Basic Information
| Provider Information | |||||||||
| NPI: | 1962586123 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | W.A. FOOTE MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HENRY FORD ALLEGIANCE HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FORD PL STE 2E | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744806 | ||||||||
| FaxNumber: | 3138761305 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | ONE JACKSON SQUARE, SUITE 400 | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178416982 | ||||||||
| FaxNumber: | 5178416987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CEBALT | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3138746764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | W.A. FOOTE MEMORIAL HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 380010 | MI | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 60-20013 | 01 | MI | PHYSICIAN'S HEALTH PLAN | OTHER | OE122 | 01 | MI | BLUE CROSS OF MICHIGAN | OTHER | 2859 | 01 | MI | HEALTH PLAN OF MICHIGAN | OTHER | 4681313-86 | 05 | MI | MEDICAID |