MEDICARE: MEDRAD CLINICS, SC

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	261QH0100X	Health Service Clinic/Center	042.617504	IL
2	261QR0200X	Radiology Clinic/Center	042.617504	IL

General Provider Information

NPI Number	:	1780815241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDRAD CLINICS, SC

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	:	PRESIDENT
Name	:	DR. KENNETH UZOMA EKECHUKWU
Credential	:	MD, MPH, FACP
Telephone Number	:	630-967-4997

Provider Enumeration Date	:	08/01/2009
Last Update Date	:	07/21/2022

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