Basic Information
| Provider Information | |||||||||
| NPI: | 1598242778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METRO INFECTIOUS DISEASE CONSULTANTS, LLC | ||||||||
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| OtherOrganizationName: | MIDC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6306544253 | ||||||||
| Practice Location | |||||||||
| Address1: | 2340 E MEYER BLVD, BLDG 2 | ||||||||
| Address2: | STE 392 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641321129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164447977 | ||||||||
| FaxNumber: | 8163618938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2018 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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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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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 502397706 | 05 | MO | MEDICAID |