Basic Information
Provider Information
NPI: 1427619386
EntityType: 2
ReplacementNPI:  
OrganizationName: METRO INFECTIOUS DISEASE CONSULTANTS, LLC
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Mailing Information
Address1: 901 MCCLINTOCK DR STE 202
Address2:  
City: BURR RIDGE
State: IL
PostalCode: 605270872
CountryCode: US
TelephoneNumber: 6302206432
FaxNumber: 6306544253
Practice Location
Address1: 4601 W 109TH ST STE 100
Address2:  
City: OVERLAND PARK
State: KS
PostalCode: 662111313
CountryCode: US
TelephoneNumber: 9139420540
FaxNumber: 6305289589
Other Information
ProviderEnumerationDate: 06/21/2019
LastUpdateDate: 06/21/2019
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AuthorizedOfficialLastName: PETRAK
AuthorizedOfficialFirstName: RUSSELL
AuthorizedOfficialMiddleName: M
AuthorizedOfficialTitleorPosition: MANAGING PARTNER
AuthorizedOfficialTelephone: 8882206432
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IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RI0200X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease

ID Information
IDTypeStateIssuerDescription
201170330A05KS MEDICAID


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