Healthcare Provider Details

I. General information

NPI: 1750685335
Provider Name (Legal Business Name): UDO G FOREMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

2537 MOMENTUM PL SUITE 200
CHICAGO IL
60689-5325
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1680
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax: 616-285-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006199
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3145
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2745
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-02569
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: