Basic Information
| Provider Information | |||||||||
| NPI: | 1235125717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO INFECTIOUS DISEASE CONSULTANTS, LLC | ||||||||
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| OtherOrganizationName: | MIDC, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MCCLINTOCK DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | PETRAK | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8882206432 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QI0500X | N | Ambulatory Health Care Facilities | Clinic/Center | Infusion Therapy | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RI0200X | 0000920-2 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.