Basic Information
| Provider Information | |||||||||
| NPI: | 1164400024 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYO CLINIC HEALTH SYSTEM-SOUTHEAST MINNESOTA REGION | ||||||||
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| OtherOrganizationName: | MAYO CLINIC HEALTH SYSTEM-RED WING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 HEWITT BLVD | ||||||||
| Address2: | |||||||||
| City: | RED WING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550662848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 HEWITT BLVD | ||||||||
| Address2: | |||||||||
| City: | RED WING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550662848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEKALA | ||||||||
| AuthorizedOfficialFirstName: | PRAVEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHEIF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5075946449 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207ZP0105X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 208M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 282N00000X | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 55485JO | 01 | MN | BCBS | OTHER | 19182 | 01 | MN | HEALTHPARTNERS | OTHER | 994210600 | 05 | MN | MEDICAID | 3945090 | 01 | MN | MEDICA | OTHER | 5009713 | 01 | MN | MEDICA | OTHER | 50658 | 01 | MN | HEALTHPARTNERS | OTHER | 9840090 | 01 | MN | MEDICA | OTHER | 990824002 | 01 | MN | MHP | OTHER | 1817HJO | 01 | MN | BCBS | OTHER | 466745000 | 05 | MN | MEDICAID | 59952JO | 01 | MN | BCBS | OTHER | 6600092 | 01 | MN | MEDICA | OTHER | 9866075 | 01 | MN | MEDICA | OTHER |