MEDICARE: DR. KENNETH U EKECHUKWU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	036-083256	IL
2	207R00000X	Internal Medicine Physician	036-083256	IL
3	2085R0204X	Vascular & Interventional Radiology Physician	036-083256	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255331096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH U EKECHUKWU M.D.

Provider Business Mailing Address
First Line	:	1225 HARLEM AVE
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2407
Country	:	US
Telephone Number	:	708-657-4540
Fax Number	:	708-657-4535

Provider Business Practice Location Address
First Line	:	1225 HARLEM AVE
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2407
Country	:	US
Telephone Number	:	708-657-4540
Fax Number	:	708-657-4535

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	04/14/2025

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