1811921968 NPI number — WA FOOTE MEMORIAL HOSPITAL, INC

Table of content: (NPI 1811921968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811921968 NPI number — WA FOOTE MEMORIAL HOSPITAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WA FOOTE MEMORIAL HOSPITAL, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HENRY FORD ALLEGIANCE HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811921968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 67000
Provider Second Line Business Mailing Address:
DEPARTMENT 272801
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48267-2728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-841-7482
Provider Business Mailing Address Fax Number:
517-841-7476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 N EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49201-1753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-788-4800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP. CMO
Authorized Official Telephone Number:
517-205-6407

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 540C876160 . This is a "BCBSM/AUDIOLOGIST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CC5829 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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