1215184916 NPI number — METRO INFECTIOUS DISEASE CONSULTANTS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215184916 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:
MIDC, LLC
Provider Other Organization Name Type Code:
3
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:
1215184916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 MCCLINTOCK DRIVE
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:
60527-0844
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:
901 MCCLINTOCK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BURR RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60527-0844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-220-6432
Provider Business Practice Location Address Fax Number:
630-654-4253
Provider Enumeration Date:
08/25/2008

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: 251F00000X , with the licence number:  054015148 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1634065 . This is a "BLUE CROSS/ BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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