Provider Demographics
NPI:1881021640
Name:FOSS, BRIAN UDELL (PTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:UDELL
Last Name:FOSS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5259 TRAFFORD DR
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3484
Mailing Address - Country:US
Mailing Address - Phone:815-227-5797
Mailing Address - Fax:
Practice Address - Street 1:5668 STRATHMOOR DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5110
Practice Address - Country:US
Practice Address - Phone:815-229-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.003092225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant