Provider Demographics
NPI:1255331096
Name:EKECHUKWU, KENNETH U (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:U
Last Name:EKECHUKWU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2407
Mailing Address - Country:US
Mailing Address - Phone:708-657-4540
Mailing Address - Fax:708-657-4535
Practice Address - Street 1:1225 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2407
Practice Address - Country:US
Practice Address - Phone:708-657-4540
Practice Address - Fax:708-657-4535
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-083256207R00000X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-083256-4Medicaid
ILF18484Medicare UPIN
IL036-083256-4Medicaid