Provider Demographics
NPI:1871690057
Name:SISKIYOU RURAL HOUSECALLS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SISKIYOU RURAL HOUSECALLS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:T
Authorized Official - Last Name:WALENTA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:707-884-9004
Mailing Address - Street 1:1296 SCHEIBEL LN
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4717
Mailing Address - Country:US
Mailing Address - Phone:707-884-9004
Mailing Address - Fax:707-823-3856
Practice Address - Street 1:1296 SCHEIBEL LN
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4717
Practice Address - Country:US
Practice Address - Phone:707-884-9004
Practice Address - Fax:707-823-3856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01748003Medicaid
CAZZZ01600ZMedicare ID - Type UnspecifiedJW WITH SISKIYOU RURAL HC
NY01748003Medicaid
CAZZZ01586ZMedicare ID - Type UnspecifiedSISKIYOU RURAL HOUSECALLS
CA020A59920Medicare ID - Type UnspecifiedDR. ALAN COHN
P26226Medicare UPIN
F29055Medicare UPIN
CAZZZ29641ZMedicare ID - Type UnspecifiedJW WITH DR. LU
CAZZZ01382ZMedicare ID - Type UnspecifiedJW WITH DR CHAMBERS