Provider Demographics
NPI:1275537987
Name:SISKIYOU EYE CENTER, MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:SISKIYOU EYE CENTER, MEDICAL GROUP, PC
Other - Org Name:SISKIYOU EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BELMIRA
Authorized Official - Middle Name:PARDAL
Authorized Official - Last Name:BORG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-482-8100
Mailing Address - Street 1:648 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1710
Mailing Address - Country:US
Mailing Address - Phone:541-482-8100
Mailing Address - Fax:541-488-5081
Practice Address - Street 1:648 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1710
Practice Address - Country:US
Practice Address - Phone:541-482-8100
Practice Address - Fax:541-488-5081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR209930-10207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298084Medicaid
OR053574Medicaid
OR289751Medicaid
OR289751Medicaid
ORA37173Medicare UPIN
OR053574Medicaid
OR0000WCPBAMedicare PIN