Basic Information
Provider Information | |||||||||
NPI: | 1629000708 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WA FOOTE MEMORIAL HOSPITAL, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HENRY FORD ALLEGIANCE HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 67000 | ||||||||
Address2: | DEPARTMENT 272801 | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482672728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5178417482 | ||||||||
FaxNumber: | 5178417476 | ||||||||
Practice Location | |||||||||
Address1: | 205 N EAST AVE | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MI | ||||||||
PostalCode: | 492011753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5177884800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 04/01/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WICKENS | ||||||||
AuthorizedOfficialFirstName: | JEANNE' | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 5178416979 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WA FOOTE MEMORIAL HOSPITAL, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CFO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 500C810570 | 01 | MI | BCBSM CNP | OTHER | CC5829 | 01 | MI | RR MEDICARE | OTHER |