Healthcare Provider Details

I. General information

NPI: 1184610396
Provider Name (Legal Business Name): METRO INFECTIOUS DISEASE CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MCCLINTOCK DR SUITE 104
BURR RIDGE IL
60527-0844
US

IV. Provider business mailing address

901 MCCLINTOCK DR STE 104
BURR RIDGE IL
60527-0844
US

V. Phone/Fax

Practice location:
  • Phone: 630-986-4580
  • Fax: 630-528-9600
Mailing address:
  • Phone: 630-986-4580
  • Fax: 630-528-9600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number054-015148
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054015148
License Number StateIL

VIII. Authorized Official

Name: DR. RUSSELL MARTIN PETRAK
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 630-986-4580