Basic Information
| Provider Information | |||||||||
| NPI: | 1598776718 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WA FOOTE MEMORIAL HOSPITAL, INC | ||||||||
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| OtherOrganizationName: | ALLEGIANCE HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64000 | ||||||||
| Address2: | DRAWER 641535 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482640001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | CRNA | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | WICKENS | ||||||||
| AuthorizedOfficialFirstName: | JEANNE' | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO/SR VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5177884883 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WA FOOTE MEMORIAL HOSPITAL, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.