Provider Demographics
NPI:1750685335
Name:FOREMAN, UDO G (PA-C)
Entity Type:Individual
Prefix:
First Name:UDO
Middle Name:G
Last Name:FOREMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2537 MOMENTUM PL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5325
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:616-285-0846
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-22
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006199363A00000X
CO3145363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5410563OtherBCBSM PIN
MIN30180058Medicare PIN