Provider Demographics
NPI:1730233099
Name:SISKIYOU PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:SISKIYOU PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HULL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-479-6936
Mailing Address - Street 1:PO BOX 2630
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0239
Mailing Address - Country:US
Mailing Address - Phone:541-479-6936
Mailing Address - Fax:541-479-6939
Practice Address - Street 1:1485 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-479-6936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4659225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000584Medicaid
ORR133859Medicare ID - Type Unspecified
OR000584Medicaid