Healthcare Provider Details

I. General information

NPI: 1700999521
Provider Name (Legal Business Name): SISKIYOU PEDIATRIC CLINIC, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RAMSEY AVE STE 204
GRANTS PASS OR
97527-5792
US

IV. Provider business mailing address

700 RAMSEY AVE STE 204
GRANTS PASS OR
97527-5792
US

V. Phone/Fax

Practice location:
  • Phone: 541-955-5683
  • Fax: 541-955-0983
Mailing address:
  • Phone: 541-955-5683
  • Fax: 541-955-0983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO14538
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1568446219
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerSTEVEN MARSHAK, DO NPI
# 2
Identifier1639153380
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerDEBORAH AYOLI, CPNP NPI
# 3
Identifier1487638235
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerKELLEY BURNETT, DO NPI
# 4
Identifier299499
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 5
Identifier1750365409
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerCHARLES CRISPEN NPI

VIII. Authorized Official

Name: CHARLES RAY CRISPEN JR.
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 541-955-5683