Provider Demographics
NPI:1700999521
Name:SISKIYOU PEDIATRIC CLINIC, LLP
Entity type:Organization
Organization Name:SISKIYOU PEDIATRIC CLINIC, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:CRISPEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:541-955-5683
Mailing Address - Street 1:700 RAMSEY AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5792
Mailing Address - Country:US
Mailing Address - Phone:541-955-5683
Mailing Address - Fax:541-955-0983
Practice Address - Street 1:700 RAMSEY AVE STE 204
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5792
Practice Address - Country:US
Practice Address - Phone:541-955-5683
Practice Address - Fax:541-955-0983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO14538208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1568446219OtherSTEVEN MARSHAK, DO NPI
OK1639153380OtherDEBORAH AYOLI, CPNP NPI
OR1487638235OtherKELLEY BURNETT, DO NPI
OR299499Medicaid
OR1750365409OtherCHARLES CRISPEN NPI
OR1568446219OtherSTEVEN MARSHAK, DO NPI
OR383843Medicare ID - Type UnspecifiedCHARLES R. CRISPEN
OR1487638235OtherKELLEY BURNETT, DO NPI
OR1750365409OtherCHARLES CRISPEN NPI
ORF79019Medicare UPIN