Provider Demographics
NPI:1649345448
Name:RIVERSIDE HOSPITAL CORPORATION
Entity type:Organization
Organization Name:RIVERSIDE HOSPITAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-283-1107
Mailing Address - Street 1:533 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1919
Mailing Address - Country:US
Mailing Address - Phone:574-283-1104
Mailing Address - Fax:574-283-2178
Practice Address - Street 1:533 N NILES AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1919
Practice Address - Country:US
Practice Address - Phone:574-283-1104
Practice Address - Fax:574-283-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200264930AMedicaid
IN154049Medicare ID - Type Unspecified