Provider Demographics
NPI:1710070701
Name:RIVEREDGE HOSPITAL INC
Entity Type:Organization
Organization Name:RIVEREDGE HOSPITAL INC
Other - Org Name:AERIES HEALTHCARE OF ILLINOIS INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SR VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:FILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-274-9038
Mailing Address - Street 1:8311 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2529
Mailing Address - Country:US
Mailing Address - Phone:708-771-7000
Mailing Address - Fax:708-209-2280
Practice Address - Street 1:8311 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2529
Practice Address - Country:US
Practice Address - Phone:708-771-7000
Practice Address - Fax:708-209-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1720146283Q00000X
IL0005124283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL144009Medicare Oscar/Certification