Siskiyou Hospital Inc
Organization Active NPI Rural Health Clinic/Center · Etna, CA
NPI 1336330646 · NPPES record last updated Dec 26, 2019
Key facts
- NPI
- 1336330646
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- SISKIYOU HOSPITAL INC
- Practice address
- 8 Commercial Street
Etna, CA 96027 - Phone
- (530) 467-5393
- Fax
- (530) 467-5355
- NPI assigned
- Aug 5, 2007
- Organization subpart
- Yes
- Parent organization (as reported)
- SISKIYOU HOSPITAL INC
Authorized official
- Name
- Jonathon C Andrus
- Title
- Ceo
- Phone
- (530) 842-4121
Owners & managing parties with NPI records 3
-
Louis Derouchey, MD
-
Vina K Swenson, MD
Other NPIs with the same Medicare PAC ID 1
Related certifications (CCN) 2
Practitioners 100
-
Kelly Barrett, M.D
-
Savannah Lea Kenny, FNP
-
Roy E Smith, MD
-
Olcay Aksoy, M.D.
-
Jean Claude Bassila, M.D.
-
Paul V. Beck, M.D.
-
Amber Bernelis, PA-C
-
Aditi Bhaduri, M.D.
-
Kathleen Brandt, FNP
-
Cheryl Ann Busby, LCSW
-
Melissa Sue Butts, D.O.
-
Vanessa L. Demoss, FNP-C
-
Louis Derouchey, MD
-
Teresa Jean Dunton, PMHNP-BC
-
Peggy M Einsele, FNP-C
-
Shannon M Ferguson, FNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D0953717 | Scott Valley Rural Health Clinic | Certificate of waiver | Oct 23, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
Rural health clinic certification: CCN 058517
- Legal name
- SISKIYOU HOSPITAL INC
- Doing business as
- SCOTT VALLEY RURAL HEALTH CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Sep 7, 1995
- Last certification
- Sep 23, 2015
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jul 15, 1962 in CA
- Enrollment address
- 8 Commercial Street
Etna, CA 96027 - Related CCNs
- 051316
All disclosed owners & managing parties 19
| Name | Role | Since | Share |
|---|---|---|---|
| Louis F Derouchey |
Corporate Officer |
Jan 1, 2000 | |
| Corporate Director |
Jan 1, 2000 | ||
| Kristi Von Tickner |
Corporate Officer |
Jan 1, 2019 | |
| Corporate Director |
Jan 1, 2019 | ||
| Jerome Churchill |
Corporate Officer |
Jan 1, 2014 | |
| Corporate Director |
Jan 1, 2014 | ||
| Siskiyou Hospital Inc |
Operational/Managerial Control | Jan 1, 2009 | 100% |
| Vina K Swenson |
Corporate Officer |
Jan 1, 2023 | |
| Corporate Director |
Jan 1, 2023 | ||
| Darrin W Mercier |
Corporate Officer |
Jul 1, 1999 | |
| Corporate Director |
Jul 1, 1999 | ||
| Michael Madden |
Corporate Director |
Oct 2, 2007 | |
| W-2 Managing Employee |
Oct 2, 2007 | ||
| James M Quisenberry |
Corporate Officer |
Jan 1, 2012 | |
| Corporate Director |
Jan 1, 2012 | ||
| Lorah Guse |
Corporate Officer |
Jan 1, 2022 | |
| Corporate Director |
Jan 1, 2022 | ||
| William Broeckel |
Corporate Officer |
Jan 1, 2021 | |
| Corporate Director |
Jan 1, 2021 | ||
| Carrie L Hayden |
Corporate Officer |
May 1, 1999 | |
| Corporate Director |
May 10, 1999 | ||
| Judith L Baker |
Corporate Officer |
Jan 1, 2006 | |
| Corporate Director |
Jan 1, 2012 | ||
| Dwayne Jones |
Corporate Officer |
Jan 1, 2009 | |
| Corporate Director |
Jan 1, 2009 | ||
| Susan Westphal |
Corporate Director |
Jan 9, 2015 | |
| W-2 Managing Employee |
Jan 9, 2015 | ||
| Douglas J Langford |
Corporate Officer |
Mar 1, 1998 | |
| Corporate Director |
Mar 1, 1998 | ||
| Kelly Martin |
Corporate Director |
Oct 1, 2018 | |
| W-2 Managing Employee |
Oct 1, 2018 | ||
| Deanne I Terry |
Corporate Officer |
Jan 6, 2006 | |
| Corporate Director |
Jan 6, 2006 | ||
| Lawrence D Mulloy |
Corporate Officer |
Apr 1, 1992 | |
| Corporate Director |
Apr 1, 1992 | ||
| Jonathon C Andrus |
Corporate Officer |
Jan 1, 2009 | |
| Corporate Director |
Jan 1, 2009 | ||
| W-2 Managing Employee |
Jan 1, 2009 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20191120000955 | CA | Part a Provider - Rural Health Clinic | 1254223134 | Practice locations: Etna, CA |
National Provider Directory
- Part of
- Siskiyou Hospital Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 230000035 | CA | |
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
8 Commercial Street
Etna, CA 96027
Mailing address
444 Bruce Street
Yreka, CA 96097-3450
Phone (530) 841-6256
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| RHM18517F | Medicaid | CA | |
| BCP18517F | Medicaid | CA |
Other providers in Etna, CA
- Donald Dean Murphy
- Hillary Plank-Gentry
- Lynda Pollard
- Rockside, Inc.
- Scott Valley Pharmacy Inc
- Laurie Sweezey
- Donna Catherine Wilcox
- Michael William Willett
All providers in Etna, CA · Rural Health Clinic/Center in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 26, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.