Basic Information
| Provider Information | |||||||||
| NPI: | 1417056532 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW LIFE EDUCATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 781 | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159357256 | ||||||||
| FaxNumber: | 8159357340 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 E COURT ST. | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159355433 | ||||||||
| FaxNumber: | 8159351187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIRCHNER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP COMMUNITY CENTERS | ||||||||
| AuthorizedOfficialTelephone: | 8159357256 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036100101 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.