Healthcare Provider Details

I. General information

NPI: 1982703005
Provider Name (Legal Business Name): RIVERSIDE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 S MAIN ST.
HOPKINS PARK IL
60944-9998
US

IV. Provider business mailing address

PO BOX 781
KANKAKEE IL
60901-0781
US

V. Phone/Fax

Practice location:
  • Phone: 815-944-5545
  • Fax: 815-944-6723
Mailing address:
  • Phone: 815-935-7256
  • Fax: 815-935-7864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number007
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA K VILT
Title or Position: CFO
Credential:
Phone: 815-933-1671