Basic Information
| Provider Information | |||||||||
| NPI: | 1942277769 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYO CLINIC HEALTH SYSTEM-SOUTHWEST MINNESOTA REGION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MAYO CLINIC HEALTH SYSTEM-WASECA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 501 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | WASECA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078351210 | ||||||||
| FaxNumber: | 5077818945 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | WASECA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078351210 | ||||||||
| FaxNumber: | 5077818945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEKALA | ||||||||
| AuthorizedOfficialFirstName: | PRAVEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5075946449 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 323805 | MN | N | Hospitals | General Acute Care Hospital | Critical Access | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 1710EWA | 01 | MN | BCBS | OTHER | 204547800 | 05 | MN | MEDICAID |