Provider Demographics
NPI:1215184916
Name:METRO INFECTIOUS DISEASE CONSULTANTS, LLC
Entity Type:Organization
Organization Name:METRO INFECTIOUS DISEASE CONSULTANTS, LLC
Other - Org Name:MIDC, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOWALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-220-6432
Mailing Address - Street 1:901 MCCLINTOCK DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0844
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-654-4253
Practice Address - Street 1:901 MCCLINTOCK DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0844
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:630-654-4253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054015148251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634065OtherBLUE CROSS/ BLUE SHIELD
ILBM8662555OtherMIDC PHARMACY DEA NUMBER