Basic Information
| Provider Information | |||||||||
| NPI: | 1558774869 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CRISIS RESIDENTIAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159357256 | ||||||||
| FaxNumber: | 8159357490 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609013729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159357256 | ||||||||
| FaxNumber: | 8159357490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2014 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 8159357256 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERSIDE MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0002014 | IL | Y | Hospitals | General Acute Care Hospital |
No ID Information.