Provider Demographics
NPI:1578890653
Name:SISKIYOU HOSPITAL INC.
Entity Type:Organization
Organization Name:SISKIYOU HOSPITAL INC.
Other - Org Name:SISKIYOU FAMILY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-842-4121
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:530-841-0913
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3354
Practice Address - Country:US
Practice Address - Phone:530-842-0817
Practice Address - Fax:530-842-3597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53948FMedicaid
CA55-3948OtherMEDICARE RHC #