1598242778 NPI number — METRO INFECTIOUS DISEASE CONSULTANTS, LLC

Table of content: (NPI 1598242778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598242778 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:
1598242778
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 MCCLINTOCK DR STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-0872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-220-6432
Provider Business Mailing Address Fax Number:
630-654-4253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2340 E MEYER BLVD, BLDG 2
Provider Second Line Business Practice Location Address:
STE 392
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64132-1129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-444-7977
Provider Business Practice Location Address Fax Number:
816-361-8938
Provider Enumeration Date:
07/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
PETRAK
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
888-220-6432

Provider Taxonomy Codes

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

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

  • Identifier: 502397706 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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