Provider Demographics
NPI:1336330646
Name:SISKIYOU HOSPITAL INC
Entity Type:Organization
Organization Name:SISKIYOU HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANDRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-842-4121
Mailing Address - Street 1:444 BRUCE STREET
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:530-841-6256
Mailing Address - Fax:530-842-0232
Practice Address - Street 1:8 COMMERCIAL STREET
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:CA
Practice Address - Zip Code:96027
Practice Address - Country:US
Practice Address - Phone:530-467-5393
Practice Address - Fax:530-467-5355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISKIYOU HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-05
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000035261QR1300X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM18517FMedicaid
CABCP18517FMedicaid
058517Medicare Oscar/Certification