Basic Information
| Provider Information | |||||||||
| NPI: | 1215184916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO INFECTIOUS DISEASE CONSULTANTS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIDC, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DRIVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6306544253 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MCCLINTOCK DRIVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6306544253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2008 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | KOWALSKI | ||||||||
| AuthorizedOfficialFirstName: | TARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8882206432 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251F00000X | 054015148 | IL | Y | Agencies | Home Infusion |
ID Information
| ID | Type | State | Issuer | Description | 1634065 | 01 | IL | BLUE CROSS/ BLUE SHIELD | OTHER | BM8662555 | 01 | IL | MIDC PHARMACY DEA NUMBER | OTHER |