Basic Information
| Provider Information | |||||||||
| NPI: | 1578729976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROGAN | ||||||||
| FirstName: | AUTUMN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 404 W FOUNTAIN ST | ||||||||
| Address2: | MAYO CLINIC HEALTH SYSTEM, DEPT OF EM | ||||||||
| City: | ALBERT LEA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560072437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073732384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 404 W FOUNTAIN ST | ||||||||
| Address2: | MAYO CLINIC HEALTH SYSTEM, DEPT OF EM | ||||||||
| City: | ALBERT LEA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560072437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073732384 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 21206 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | A117018 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 56455-20 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 53558 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 21206 | 01 | MN | MN PERMIT NUMBER | OTHER | P01251460 | 01 | MN | RAILROAD MEDICARE | OTHER |