Provider Demographics
NPI:1740346451
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 1:611 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:PEOTONE
Practice Address - State:IL
Practice Address - Zip Code:60468-9590
Practice Address - Country:US
Practice Address - Phone:815-935-3272
Practice Address - Fax:815-937-7961
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-28
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1001668251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50482OtherBLUE CROSS BLUE SHIELD
ILMW10893OtherMEDICARE ELECTRONIC NUMBE
IL216396OtherPERSONAL CARE
IL50482OtherBLUE CROSS BLUE SHIELD
IL147400Medicare Oscar/Certification