Basic Information
| Provider Information | |||||||||
| NPI: | 1114971660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE HEALTHCARE SYSTEM, L.P. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | RIVERSIDE COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517883000 | ||||||||
| FaxNumber: | 9097883201 | ||||||||
| Practice Location | |||||||||
| Address1: | 4445 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517883000 | ||||||||
| FaxNumber: | 9097883201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LACAZE | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | TODD | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9517883000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 923856 | 05 | AZ | MEDICAID | 10025186300 | 05 | NE | MEDICAID | ZZZA3301Z | 01 | CA | BLUE SHIELD | OTHER | 003498300 | 05 | ID | MEDICAID | 050022 | 01 | CA | BLUE CROSS | OTHER | 3021292 | 05 | WA | MEDICAID | 12614 | 05 | TN | MEDICAID | HSC30022G | 05 | CA | MEDICAID |