Provider Demographics
NPI:1619144870
Name:RIVERSIDE MEDICAL CENTER
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-935-7256
Mailing Address - Street 1:350 N WALL ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2901
Mailing Address - Country:US
Mailing Address - Phone:815-935-7256
Mailing Address - Fax:815-935-7490
Practice Address - Street 1:350 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2901
Practice Address - Country:US
Practice Address - Phone:815-935-7256
Practice Address - Fax:815-935-7490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-15
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002014261QR0405X, 276400000X, 282N00000X, 324500000X, 3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No282N00000XHospitalsGeneral Acute Care Hospital
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========009Medicaid