Basic Information
| Provider Information | |||||||||
| NPI: | 1164463659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAYO CLINIC HEALTH SYSTEM-LAKE CITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W GRANT ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550411143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513453321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 W GRANT ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550411143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513453321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | MEKALA | ||||||||
| AuthorizedOfficialFirstName: | PRAVEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5075946449 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | MN | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.