Provider Demographics
NPI:1417061193
Name:RIVERSIDE HEALTH SYSTEM
Entity type:Organization
Organization Name:RIVERSIDE HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMBIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-933-1671
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-0781
Mailing Address - Country:US
Mailing Address - Phone:815-935-7526
Mailing Address - Fax:815-935-7340
Practice Address - Street 1:1905 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3163
Practice Address - Country:US
Practice Address - Phone:815-935-7526
Practice Address - Fax:815-935-7340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL356253Medicare ID - Type UnspecifiedL58649
IL356255Medicare ID - Type UnspecifiedK22840
IL356256Medicare ID - Type UnspecifiedL72683
IL356254Medicare ID - Type UnspecifiedK26453
IL356255Medicare ID - Type UnspecifiedK25675
IL356253Medicare ID - Type UnspecifiedL58648
IL356255Medicare ID - Type UnspecifiedK20703
IL356255Medicare ID - Type UnspecifiedK24406
IL356256Medicare ID - Type UnspecifiedK14665
IL356253Medicare ID - Type UnspecifiedL58647
IL356255Medicare ID - Type UnspecifiedK13490
IL356250Medicare ID - Type UnspecifiedK29829
IL356254Medicare ID - Type UnspecifiedL95639
IL356254Medicare ID - Type UnspecifiedK22841
IL356255Medicare ID - Type UnspecifiedK31802
IL356254Medicare ID - Type UnspecifiedK04845
IL356250Medicare ID - Type UnspecifiedL34473
IL356255Medicare ID - Type UnspecifiedL92643
IL356256Medicare ID - Type UnspecifiedK02140
IL356256Medicare ID - Type UnspecifiedK24393