Healthcare Provider Details

I. General information

NPI: 1417061193
Provider Name (Legal Business Name): RIVERSIDE HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 W COURT ST
KANKAKEE IL
60901-3163
US

IV. Provider business mailing address

PO BOX 781
KANKAKEE IL
60901-0781
US

V. Phone/Fax

Practice location:
  • Phone: 815-935-7526
  • Fax: 815-935-7340
Mailing address:
  • Phone: 815-935-7526
  • Fax: 815-935-7340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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