MEDICARE: RIVERSIDE MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	1001668	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MW10893	OTHER	IL	MEDICARE ELECTRONIC NUMBE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50482	OTHER	IL	BLUE CROSS BLUE SHIELD
3	216396	OTHER	IL	PERSONAL CARE

General Provider Information

NPI Number	:	1740346451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE MEDICAL CENTER

Provider Business Mailing Address
First Line	:	350 N WALL ST
Second Line	:
City	:	KANKAKEE
State	:	IL
Zip	:	60901-2901
Country	:	US
Telephone Number	:	815-933-1671
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 DIVISION STREET
Second Line	:
City	:	PEOTONE
State	:	IL
Zip	:	60468-9590
Country	:	US
Telephone Number	:	815-935-3272
Fax Number	:	815-937-7961

Authorized Official
Title or Position	:	CFO
Name	:	MR. BILL DOUGLAS
Credential	:
Telephone Number	:	815-935-7256

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	09/30/2019

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Directions to “RIVERSIDE MEDICAL CENTER ” Practice Location

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