Healthcare Provider Details

I. General information

NPI: 1336354430
Provider Name (Legal Business Name): RIVERSIDE HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/21/2022
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N WALL ST SUITE 200
KANKAKEE IL
60901-2942
US

IV. Provider business mailing address

500 N WALL ST SUITE 200
KANKAKEE IL
60901-2942
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-1237
  • Fax: 815-933-0662
Mailing address:
  • Phone: 815-937-1237
  • Fax: 815-933-0662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: PHILLIP KAMBIC
Title or Position: CEO
Credential:
Phone: 815-933-1671