Siskiyou Hospital Inc

Primary specialty

Rural Health Clinic/CenterTaxonomy code 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

Last updated

Dec 26, 2019By the provider in NPPES

Organization subpart

Yes

Parent organization

SISKIYOU HOSPITAL INCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jonathon C Andrus

Title

Ceo

Phone

(530) 842-4121

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1336330646. Details of each certification follow.

• CCN 058517 Rural health clinic · Active · Details

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

CorporationNon-profit

Incorporated

Jul 15, 1962 in CA

Enrollment address

8 Commercial Street
Etna, CA 96027

Related CCNs

051316

Related certifications (CCN) 2

Facilities connected through Provider of Services related, parent or unit certification numbers.

• Siskiyou Hospital, Inc.

  dba Fairchild Medical Center

  • Critical Access Hospital
  • Yreka, CA
  • NPI 1093892275

  Parent provider

  Provider of Services
• Siskiyou Hospital, Inc.

  dba Fairchild Medical Center

  • Critical Access Hospital
  • Yreka, CA
  • NPI 1952701369

  Parent provider

  Provider of Services

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• Siskiyou Hospital, Inc.

  dba Fairchild Medical Center

  • Critical Access Hospital
  • Yreka, CA
  • NPI 1093892275

  1254223134

  Same PAC ID

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Part of

Siskiyou Hospital Inc

All disclosed owners & managing parties 19

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Louis Derouchey, MD

  • Family Medicine Physician
  • Yreka, CA
  • NPI 1407850498

  Corporate Director, Corporate Officer

  CMS ownership
• Siskiyou Hospital, Inc.

  dba Fairchild Medical Center

  • Critical Access Hospital
  • Yreka, CA
  • NPI 1093892275

  Operational/Managerial Control

  CMS ownership
• Vina K Swenson, MD

  • Pediatrics Physician
  • Yreka, CA
  • NPI 1447341995

  Corporate Director, Corporate Officer

  CMS ownership

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Kelly Barrett, M.D

  • Internal Medicine Physician
  • Yreka, CA
  • NPI 1578201505
  NPD (past)
• Savannah Lea Kenny, FNP

  • Family Medicine Physician
  • Yreka, CA
  • NPI 1538635065
  NPD (past)
• Kasia Nicole Mannix, RN

  • Family Nurse Practitioner
  • Etna, CA
  • NPI 1588996060
  NPD (past)
• David Earl Marriott, MD

  • Pediatrics Physician
  • Yreka, CA
  • NPI 1194213678
  NPD (past)
• Carrie Christine McNeely-Schenone, FNP

  • Nurse Practitioner
  • Yreka, CA
  • NPI 1386309623
  NPD (past)
• Roy E Smith, MD

  • Addiction Medicine (Family Medicine) Physician
  • Yreka, CA
  • NPI 1245287291
  NPD (past)
• Michael William Willett, M.D.

  • Family Medicine Physician
  • Etna, CA
  • NPI 1134182348
  NPD (past)
• Robert Everett Leeth, FNP, PMHNP

  • Psychiatric/Mental Health Nurse Practitioner
  • Coeur d'Alene, ID
  • NPI 1881657237
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1186272000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1577318400000",
    "number": "1336330646",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "444 BRUCE STREET",
            "city": "YREKA",
            "state": "CA",
            "postal_code": "960973450",
            "telephone_number": "530-841-6256",
            "fax_number": "530-842-0232"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8 COMMERCIAL STREET",
            "city": "ETNA",
            "state": "CA",
            "postal_code": "96027",
            "telephone_number": "530-467-5393",
            "fax_number": "530-467-5355"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SISKIYOU HOSPITAL INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SISKIYOU HOSPITAL INC",
        "enumeration_date": "2007-08-05",
        "last_updated": "2019-12-26",
        "certification_date": "2019-12-26",
        "status": "A",
        "authorized_official_last_name": "ANDRUS",
        "authorized_official_first_name": "JONATHON",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "530-842-4121"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "CA",
            "license": "230000035",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "RHM18517F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "BCP18517F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Donald Dean Murphy, RPH
• Hillary Plank-Gentry
• Lynda Pollard
• Rockside, Inc. (Rockside Ranch)
• Scott Valley Pharmacy Inc (Scott Valley Drug)
• Laurie Sweezey
• Donna Catherine Wilcox, PAC
• Michael William Willett, M.D.

• Rural Health Clinic/Center in Etna, CA
• Providers in Etna, CA by specialty
• Rural Health Clinic/Center in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 26, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.