Basic Information
Provider Information | |||||||||
NPI: | 1982703005 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVERSIDE MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PEMBROKE COMMUNITY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 781 | ||||||||
Address2: |   | ||||||||
City: | KANKAKEE | ||||||||
State: | IL | ||||||||
PostalCode: | 609010781 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8159357256 | ||||||||
FaxNumber: | 8159357864 | ||||||||
Practice Location | |||||||||
Address1: | 3400 S MAIN ST. | ||||||||
Address2: |   | ||||||||
City: | HOPKINS PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 609449998 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8159445545 | ||||||||
FaxNumber: | 8159446723 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TRICE | ||||||||
AuthorizedOfficialFirstName: | DEBORAH | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | CHC SYSTEM DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8159368900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | RIVERSIDE MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 007 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.