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General NPI Number Information
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NPI Number | 1184610396
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Entity Type | Organization
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Legal Business Name | METRO INFECTIOUS DISEASE CONSULTANTS LLC
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Dates
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Enumeration Date | 09/22/2005
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 901 MCCLINTOCK DR SUITE 104
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City | BURR RIDGE
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State | IL
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Zip | 60527-0844
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Country | US
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Telephone | 630-986-4580
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Fax | 630-528-9600
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Provider Business Mailing Address
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Address Line | 901 MCCLINTOCK DR STE 104
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City | BURR RIDGE
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State | IL
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Zip | 60527-0844
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Country | US
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Telephone | 630-986-4580
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Fax | 630-528-9600
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. RUSSELL MARTIN PETRAK
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Credential | MD
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Telephone | 630-986-4580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251F00000X
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Taxonomy Name | Home Infusion Agency
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License Number | 054-015148
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054015148
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License Number State | IL
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