Provider Demographics
NPI:1093892275
Name:SISKIYOU HOSPITAL, INC.
Entity Type:Organization
Organization Name:SISKIYOU HOSPITAL, INC.
Other - Org Name:FAIRCHILD MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDRUS
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:530-841-6200
Mailing Address - Street 1:444 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3450
Mailing Address - Country:US
Mailing Address - Phone:530-842-4121
Mailing Address - Fax:530-841-6242
Practice Address - Street 1:444 BRUCE ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3450
Practice Address - Country:US
Practice Address - Phone:530-842-4121
Practice Address - Fax:530-841-6242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000035261QD0000X, 261QR1300X, 275N00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP40217FMedicaid
CA058634Medicaid
CAZZR00217FMedicaid
CAZZZJ4702ZOtherBLUE SHIELD
CA058634Medicare Oscar/Certification
CAZZZ92589ZMedicare PIN
CAZZR00217FMedicaid
CA058634Medicaid