Provider Demographics
NPI:1194245472
Name:W. A. FOOTE MEMORIAL HOSPITAL, INC
Entity type:Organization
Organization Name:W. A. FOOTE MEMORIAL HOSPITAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-205-6407
Mailing Address - Street 1:PO BOX 64000 DEPT 64787
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48264-0001
Mailing Address - Country:US
Mailing Address - Phone:517-205-7843
Mailing Address - Fax:517-205-7419
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-7843
Practice Address - Fax:517-205-7419
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HENRY FORD ALLEGIANCE HEALTH GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-27
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000042085R0001X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI106000004OtherSTATE LICENSE NUMBER