Basic Information
| Provider Information | |||||||||
| NPI: | 1922164458 | ||||||||
| 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: | 8159331671 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159331671 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | 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 | 3336H0001X | 980844 | IL | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 216396 | 01 | IL | PERSONAL CARE | OTHER | 04630122 | 01 | IL | BLUE SHIELD | OTHER |