Basic Information
Provider Information | |||||||||
NPI: | 1346258100 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAYO CLINIC HEALTH SYSTEM-SOUTHEAST MINNESOTA REGION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAYO CLINIC HEALTH SYSTEM-ALBERT LEA AND AUSTIN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 FIRST DRIVE NW | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | MN | ||||||||
PostalCode: | 55912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5074337351 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 404 W FOUNTAIN ST | ||||||||
Address2: |   | ||||||||
City: | ALBERT LEA | ||||||||
State: | MN | ||||||||
PostalCode: | 560072437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073732384 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2006 | ||||||||
LastUpdateDate: | 03/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MEKALA | ||||||||
AuthorizedOfficialFirstName: | PRAVEEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5075946449 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 330838 | MN | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | P375 | 01 | MN | UCARE | OTHER | 538K1AL | 01 | MN | BCBS | OTHER | CD5413 | 01 | MN | MCRR | OTHER | CD7991 | 01 | IA | MCRR | OTHER | 0512244 | 01 | IA | IA MA | OTHER | 136C4 | 01 | MN | VA | OTHER |