Provider Demographics
NPI:1962586123
Name:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:W.A. FOOTE MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CEBALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-874-6764
Mailing Address - Street 1:1 FORD PL STE 2E
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:313-876-1305
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:ONE JACKSON SQUARE, SUITE 400
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-841-6982
Practice Address - Fax:517-841-6987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:W.A. FOOTE MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-24
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI380010251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI60-20013OtherPHYSICIAN'S HEALTH PLAN
MIOE122OtherBLUE CROSS OF MICHIGAN
MI2859OtherHEALTH PLAN OF MICHIGAN
MI4681313-86Medicaid
MI237405Medicare Oscar/Certification
MI=========-030OtherTRICARE