1073854600 NPI number — METRO INFECTIOUS DISEASE CONSULTANTS, LLC

Table of content: (NPI 1073854600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073854600 NPI number — METRO INFECTIOUS DISEASE CONSULTANTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO INFECTIOUS DISEASE CONSULTANTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073854600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 MCCLINTOCK DR
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-0871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-220-6432
Provider Business Mailing Address Fax Number:
630-734-4715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13657 W MCDOWELL RD
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85395-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-328-7794
Provider Business Practice Location Address Fax Number:
623-328-7932
Provider Enumeration Date:
03/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KOWALSKI
Authorized Official First Name:
TARA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
888-220-6432

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 780223 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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