Healthcare Provider Details

I. General information

NPI: 1235125717
Provider Name (Legal Business Name): METRO INFECTIOUS DISEASE CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MCCLINTOCK DR SUITE 202
BURR RIDGE IL
60527-0844
US

IV. Provider business mailing address

901 MCCLINTOCK DR STE 202
BURR RIDGE IL
60527-0844
US

V. Phone/Fax

Practice location:
  • Phone: 888-220-6432
  • Fax: 630-734-4715
Mailing address:
  • Phone: 888-220-6432
  • Fax: 630-734-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number0000920-2
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL M PETRAK
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 888-220-6432