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Riverside Medical Center

Organization Active NPI Family Medicine Physician · Hopkins Park, IL

NPI 1982703005 · NPPES record last updated Mar 29, 2024

Key facts

NPI
1982703005
Entity type
Organization (NPI type 2)
Primary specialty
Family Medicine Physician 207Q00000X
License
007 (IL)
Legal business name
RIVERSIDE MEDICAL CENTER
Practice address
3400 S Main St.
Hopkins Park, IL 60944-9998
Phone
(815) 944-5545
Fax
(815) 944-6723
NPI assigned
Sep 22, 2006
Organization subpart
Yes
Parent organization (as reported)
RIVERSIDE MEDICAL CENTER

Authorized official

Name
Mrs. Patricia K Vilt
Title
Cfo
Phone
(815) 933-1671

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 12

Organizations that report the same tax identification number in the National Provider Directory.

Facilities connected through Provider of Services related, parent or unit certification numbers.

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D0646704Pembroke Community Health Center
3400 S Main St, Hopkins Park, IL 60944		Certificate of waiverApr 17, 2027

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in IL

Rural health clinic certification: CCN 143976

Legal name
RIVERSIDE MEDICAL CENTER
Doing business as
PEMBROKE COMMUNITY HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 9, 1990
Last certification
Sep 15, 2020
Ownership / control type
2B
Organization structure
Corporation · Non-profit
Incorporated
May 20, 1959 in IL
Enrollment address
3400 S. Main Street
Hopkins Park, IL 60944-9998
Related CCNs
140186

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Saroja Yalamanchili
Individual 		Corporate Director
Board Member		 Jan 1, 2023
Francis Smith
Individual 		Corporate Director
Board Member		 Jan 1, 2012
Lisa Dugan
Individual 		Corporate Director
Board Member		 Jan 1, 2012
David Baron
Individual 		Corporate Director
Board Member		 Jan 1, 2023
Nadeem Ansari
Individual 		Corporate Director
Board Member		 Jan 1, 2012
Phillip M. Kambic
Individual 		Corporate Officer
President/Ceo		 Jan 1, 2018
W-2 Managing Employee
Ceo		 Jan 1, 2006
Patricia K Vilt
Individual 		Corporate Officer
Cfo		 Jan 1, 2022
W-2 Managing Employee
Cfo		 Apr 15, 2010
Michael Boyd
Individual 		Corporate Director
Board Member		 Jan 1, 2023
Ann Offermann
Individual 		Corporate Director
Board Member		 Jan 1, 2023
Jake Lee
Individual 		Corporate Director
Board Member		 Jan 1, 2023
Richard P Schiltz
Individual 		W-2 Managing Employee
Director of Finance		 Jan 1, 2018
Amber Residori
Individual 		Corporate Director
Board Member		 Jan 1, 2023
Harry Simmon
Individual 		Corporate Director
Board Member		 Jan 1, 2012
Stonewall McCuiston
Individual 		Corporate Director
Board Member		 Jan 1, 2012

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Miller Health Care Center
Kankakee, IL · CCN 145843		 Skilled nursing facility Operational/Managerial Control Jan 1, 2024

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040130000202 IL Part B Supplier - Clinic/Group Practice 5991608549 Receives reassigned benefits from 3 practitioners
1 other NPI on this enrollment
Practice locations: Bourbonnais, IL; Pembroke Township, IL
O20100525000453 IL Part a Provider - Rural Health Clinic 5991608549 Practice locations: Hopkins Park, IL

National Provider Directory

Tax ID family
Pembroke Clinic (13 organizations share this tax ID)
Part of
Pembroke Clinic

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 207Q00000X 007 IL Yes
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

3400 S Main St.
Hopkins Park, IL 60944-9998

Mailing address

PO Box 781
Kankakee, IL 60901-0781
Phone (815) 935-7256

Other names

  • Pembroke Community Health Center Doing business as

Other providers in Hopkins Park, IL

All providers in Hopkins Park, IL · Family Medicine Physician in Illinois

Sources for this page

Verify at the official NPI Registry.