Provider Demographics
NPI:1598242778
Name:METRO INFECTIOUS DISEASE CONSULTANTS, LLC
Entity Type:Organization
Organization Name:METRO INFECTIOUS DISEASE CONSULTANTS, LLC
Other - Org Name:MIDC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETRAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-220-6432
Mailing Address - Street 1:901 MCCLINTOCK DR STE 202
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-654-4253
Practice Address - Street 1:2340 E MEYER BLVD, BLDG 2
Practice Address - Street 2:STE 392
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-1129
Practice Address - Country:US
Practice Address - Phone:816-444-7977
Practice Address - Fax:816-361-8938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502397706Medicaid