Basic Information
| Provider Information | |||||||||
| NPI: | 1982093837 | ||||||||
| EntityType: | 2 | ||||||||
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| 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: | 01/15/2015 | ||||||||
| LastUpdateDate: | 01/15/2015 | ||||||||
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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 | 273R00000X | 0002014 | IL | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 1538208210 | 01 | IL | HOSPITAL NPI | OTHER | 360 | 01 | IL | BLUE CROSS | OTHER | 026741200 | 01 | IL | BLACK LUNG | OTHER | 366869400 | 01 | IL | DEPARTMENT OF LABOR | OTHER | L006923 | 01 | IL | TRICARE | OTHER |