Provider Demographics
NPI:1417056532
Name:RIVERSIDE MEDICAL CENTER
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER
Other - Org Name:NEW LIFE EDUCATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP COMMUNITY CENTERS
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIRCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-935-7256
Mailing Address - Street 1:P.O. BOX 781
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901
Mailing Address - Country:US
Mailing Address - Phone:815-935-7256
Mailing Address - Fax:815-935-7340
Practice Address - Street 1:1701 E COURT ST.
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-935-5433
Practice Address - Fax:815-935-1187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid