Provider Demographics
NPI:1982703005
Name:RIVERSIDE MEDICAL CENTER
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER
Other - Org Name:PEMBROKE COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:VILT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-933-1671
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-0781
Mailing Address - Country:US
Mailing Address - Phone:815-935-7256
Mailing Address - Fax:815-935-7864
Practice Address - Street 1:3400 S MAIN ST.
Practice Address - Street 2:
Practice Address - City:HOPKINS PARK
Practice Address - State:IL
Practice Address - Zip Code:60944-9998
Practice Address - Country:US
Practice Address - Phone:815-944-5545
Practice Address - Fax:815-944-6723
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL007207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL398350Medicare PIN
IL143976Medicare Oscar/Certification
IL143810Medicare UPIN