Provider Demographics
NPI:1922164458
Name:RIVERSIDE MEDICAL CENTER
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
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:815-933-1671
Mailing Address - Fax:
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:815-933-1671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-29
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL9808443336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216396OtherPERSONAL CARE
IL04630122OtherBLUE SHIELD
IL=========010Medicaid
IL1233990001Medicare NSC