Provider Demographics
NPI:1184610396
Name:METRO INFECTIOUS DISEASE CONSULTANTS LLC
Entity type:Organization
Organization Name:METRO INFECTIOUS DISEASE CONSULTANTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:PETRAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-986-4580
Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:STE 104
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0844
Mailing Address - Country:US
Mailing Address - Phone:630-986-4580
Mailing Address - Fax:630-528-9600
Practice Address - Street 1:901 MCCLINTOCK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0844
Practice Address - Country:US
Practice Address - Phone:630-986-4580
Practice Address - Fax:630-528-9600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:METRO INFECTIOUS DISEASE CONSULTANTS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-015148251F00000X
IL0540151483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL032-008061OtherCONTROLLED SUBSTANCE
IL032-008061OtherCONTROLLED SUBSTANCE
ILBM8662555OtherDEA NUMBER
IL=========001Medicaid