RIVERSIDE MEDICAL CENTER

Provider Demographics

• NPI: 1538208210
• Name: RIVERSIDE MEDICAL CENTER
• Entity type: Organization
• Organization Name: RIVERSIDE MEDICAL CENTER
• Authorized Official - Title/Position: VICE PRESIDENT AND CFO
• Authorized Official - Prefix: MR
• Authorized Official - First Name: BILL
• Authorized Official - Middle Name: W
• Authorized Official - Last Name: DOUGLAS
• Authorized Official - Phone: 815-935-7256
• Mailing Address - Street 1: 350 N WALL ST
• Mailing Address - City: KANKAKEE
• Mailing Address - State: IL
• Mailing Address - Zip Code: 60901-2901
• Mailing Address - Country: US
• Mailing Address - Phone: 815-935-7256
• Mailing Address - Fax: 815-935-7490
• Practice Address - Street 1: 350 N WALL ST
• Practice Address - City: KANKAKEE
• Practice Address - State: IL
• Practice Address - Zip Code: 60901-2901
• Practice Address - Country: US
• Practice Address - Phone: 815-935-7256
• Practice Address - Fax: 815-935-7490
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-02-06
• Last Update Date: 2009-12-18

Provider Licenses

State	License ID	Taxonomies
IL	0002014	273Y00000X, 273R00000X, 282N00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	282N00000X	Hospitals	General Acute Care Hospital
No	273Y00000X	Hospital Units	Rehabilitation Unit
No	273R00000X	Hospital Units	Psychiatric Unit

Provider Identifiers

State	Identifier ID	ID Type	Issuer
ND	01706	Medicaid
OH	0240224	Medicaid
NV	100508766	Medicaid
OR	262438	Medicaid
MN	301547	Medicaid
ID	807562900	Medicaid
NJ	0029751	Medicaid
IA	0585372	Medicaid
NC	1400186	Medicaid
OK	200012020A	Medicaid
MI	404727815	Medicaid
MN	410575300	Medicaid
SD	5532100	Medicaid
GA	000256935X	Medicaid
MI	304727806	Medicaid
IL	360	Other	BLUE CROSS
WI	80489100	Medicaid
KS	N193210	Medicaid
KY	01300193	Medicaid
AL	RIV0186N	Medicaid
MO	010415909	Medicaid
SD	0132100	Medicaid
KS	100455080A	Medicaid
IL	140156B000000	Other	SECTION 1011
IL	1826	Other	RESOLVE, BLUE CROSS
IL	366869400	Other	DEPT OF LABOR ACS
IL	L006923	Other	TRICARE
TX	142381601	Medicaid
IL	3977249	Other	AETNA, RESOLVE ONLY
IL	026741200	Other	BLACK LUNG
IN	100038960A	Medicaid
IL	131841	Other	COMPSYCH
AR	159332105	Medicaid
FL	900587100	Medicaid
IL	=========006	Medicaid
KS	N193210	Medicaid
IL	140156B000000	Other	SECTION 1011
IL	026741200	Other	BLACK LUNG
IL	L006923	Other	TRICARE
MI	304727806	Medicaid
MI	404727815	Medicaid
MN	410575300	Medicaid
KS	100455080A	Medicaid