Provider Demographics
NPI:1336209527
Name:FOUCHER, KWAME G (MD)
Entity type:Individual
Prefix:
First Name:KWAME
Middle Name:G
Last Name:FOUCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3878
Mailing Address - Country:US
Mailing Address - Phone:312-949-7770
Mailing Address - Fax:312-949-7742
Practice Address - Street 1:559 STATE ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1533
Practice Address - Country:US
Practice Address - Phone:219-937-3300
Practice Address - Fax:219-803-7252
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114411207Q00000X
IN01076051A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114411Medicaid
IN15-1913Medicare PIN
IN15-1958Medicare PIN
367830Medicare PIN
IL144962Medicare UPIN