Basic Information
Provider Information | |||||||||
NPI: | 1649510033 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | METRO INFECTIOUS DISEASE CONSULTANTS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 901 MCCLINTOCK DR | ||||||||
Address2: | SUITE 202 | ||||||||
City: | BURR RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 605270871 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8882206432 | ||||||||
FaxNumber: | 6306544253 | ||||||||
Practice Location | |||||||||
Address1: | 6704 BENJAMIN RD | ||||||||
Address2: | SUITE 700 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336344408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139837970 | ||||||||
FaxNumber: | 8139837977 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2013 | ||||||||
LastUpdateDate: | 02/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOWALSKI | ||||||||
AuthorizedOfficialFirstName: | TARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6306657290 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X | PH26555 | FL | Y |   | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
No ID Information.