Basic Information
| Provider Information | |||||||||
| NPI: | 1891701637 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYO CLINIC HEALTH SYSTEM-SOUTHEAST MINNESOTA REGION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAYO CLINIC HEALTH SYSTEM-ALBERT LEA AND AUSTIN | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 1ST DR NW | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559122941 | ||||||||
| 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: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEKALA | ||||||||
| AuthorizedOfficialFirstName: | PRAVEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5075946449 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | CD5413 | 01 | MN | MCRR | OTHER | 0512244 | 01 | IA | IA MA | OTHER | P375 | 01 | MN | UCARE | OTHER | 538K1AL | 01 | MN | BCBS | OTHER | CB3783 | 01 | MCRR | OTHER | 136C4 | 01 | MN | VA | OTHER | CD7991 | 01 | IA | MCRR | OTHER |