Healthcare Provider Details

I. General information

NPI: 1255331096
Provider Name (Legal Business Name): KENNETH U EKECHUKWU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 HARLEM AVE
FOREST PARK IL
60130-2407
US

IV. Provider business mailing address

1225 HARLEM AVE
FOREST PARK IL
60130-2407
US

V. Phone/Fax

Practice location:
  • Phone: 708-657-4540
  • Fax: 708-657-4535
Mailing address:
  • Phone: 708-657-4540
  • Fax: 708-657-4535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-083256
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-083256
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036-083256
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: