Healthcare Provider Details

I. General information

NPI: 1144751827
Provider Name (Legal Business Name): EKANGA SUNDAY PETTERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR
ALTON IL
62002-6722
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-7240
  • Fax:
Mailing address:
  • Phone: 812-375-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01084180A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036161607
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01084180A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: