Provider Demographics
NPI:1235125717
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:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETRAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-220-6432
Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:STE 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:630-734-4715
Practice Address - Street 1:901 MCCLINTOCK DR
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:630-734-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0000920-2207RI0200X
261QI0500X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion TherapyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0890140001Medicare NSC
ILCC3926Medicare PIN
MI1235125717Medicare PIN
IN248420Medicare PIN
ILCD3294Medicare PIN
ILCG8301Medicare PIN
IL347710Medicare PIN
IAI 10610Medicare PIN