Provider Demographics
NPI:1306174982
Name:WA FOOTE MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:WA FOOTE MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT, FINANCE CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE'
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-788-6979
Mailing Address - Street 1:700 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1626
Mailing Address - Country:US
Mailing Address - Phone:517-768-8873
Mailing Address - Fax:517-780-3816
Practice Address - Street 1:1201 E MICHIGAN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1852
Practice Address - Country:US
Practice Address - Phone:517-817-7638
Practice Address - Fax:517-817-7636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WA FOOTE MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-19
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI380010332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540C801090OtherBLUE CROSS OF MICHIGAN
MI0773750003Medicare NSC