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DSH230092BU W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health (Terminated)
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Main Details
Name
W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health
Subdivision Name
HENRY FORD ALLEGIANCE - DERMATOLOGY - Henry Ford Allegiance Dermatology
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH230092BU
Medicare Provider Number
230092
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/11/2018
Participating Start Date
4/1/2018
Participating Approval Date
1/16/2018
Last Recertification Date
8/30/2021
Termination Date
Termination Reason
4/1/2022
Site closure
Contacts
Authorizing Official
Henry Ford Allegiance Health
Jim Bongiorno, CFO
(517) 205-4899
Primary Contact
W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health
Laura Ratcliff, Manager - Pharmacy Regulatory Program
(517) 205-7557
Addresses
Street Address
3333 SPRING ARBOR RD
STE 500
JACKSON, MI 49203-8605
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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