Provider Demographics
NPI:1700833472
Name:SISKIYOU IMAGING,LLC
Entity Type:Organization
Organization Name:SISKIYOU IMAGING,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-773-2493
Mailing Address - Street 1:278 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1552
Mailing Address - Country:US
Mailing Address - Phone:541-201-4500
Mailing Address - Fax:
Practice Address - Street 1:278 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1552
Practice Address - Country:US
Practice Address - Phone:541-201-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR080223 94261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100118Medicaid
ORP00017665Medicare PIN
OR114242Medicare PIN