Healthcare Provider Details

I. General information

NPI: 1780093708
Provider Name (Legal Business Name): RIVERSIDE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 W COURT ST
KANKAKEE IL
60901-3163
US

IV. Provider business mailing address

350 N WALL ST
KANKAKEE IL
60901-2901
US

V. Phone/Fax

Practice location:
  • Phone: 815-935-7256
  • Fax: 815-935-7490
Mailing address:
  • Phone: 815-935-7256
  • Fax: 815-935-7490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number0002014
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0002014
License Number StateIL

VIII. Authorized Official

Name: MR. BILL W DOUGLAS
Title or Position: VICE PRESIDENT AND CFO
Credential:
Phone: 815-935-7256