Basic Information
| Provider Information | |||||||||
| NPI: | 1336209527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOUCHER | ||||||||
| FirstName: | KWAME | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3241 S MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606163878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129497770 | ||||||||
| FaxNumber: | 3129497742 | ||||||||
| Practice Location | |||||||||
| Address1: | 559 STATE ST | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463201533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199373300 | ||||||||
| FaxNumber: | 2198037252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-114411 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01076051A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036114411 | 05 | IL | MEDICAID |