Basic Information
| Provider Information | |||||||||
| NPI: | 1417061193 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781 | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609010781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159357526 | ||||||||
| FaxNumber: | 8159357340 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 W COURT ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609013163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159357526 | ||||||||
| FaxNumber: | 8159357340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | KAMBIC | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8159331671 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.