Basic Information
| Provider Information | |||||||||
| NPI: | 1619144870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE MEDICAL CENTER | ||||||||
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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: | 350 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159357256 | ||||||||
| FaxNumber: | 8159357490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 8159357256 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERSIDE MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 0002014 | IL | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 3245S0500X | 0002014 | IL | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 282N00000X | 0002014 | IL | N | Hospitals | General Acute Care Hospital | 324500000X | 0002014 | IL | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 276400000X | 0002014 | IL | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
No ID Information.