Provider Demographics
NPI:1164400024
Name:MAYO CLINIC HEALTH SYSTEM-SOUTHEAST MINNESOTA REGION
Entity Type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM-SOUTHEAST MINNESOTA REGION
Other - Org Name:MAYO CLINIC HEALTH SYSTEM-RED WING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEKALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-594-6449
Mailing Address - Street 1:701 HEWITT BLVD
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2848
Mailing Address - Country:US
Mailing Address - Phone:651-267-5000
Mailing Address - Fax:
Practice Address - Street 1:701 HEWITT BLVD
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2848
Practice Address - Country:US
Practice Address - Phone:651-267-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-02
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207ZP0105X, 208M00000X, 363A00000X, 363L00000X, 367500000X
MN282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55485JOOtherBCBS
MN19182OtherHEALTHPARTNERS
MN994210600Medicaid
MN3945090OtherMEDICA
MN5009713OtherMEDICA
MN50658OtherHEALTHPARTNERS
MN9840090OtherMEDICA
MN990824002OtherMHP
MN1817HJOOtherBCBS
MN466745000Medicaid
MN59952JOOtherBCBS
MN6600092OtherMEDICA
MN9866075OtherMEDICA
MN6600092OtherMEDICA
MN994210600Medicaid
MN466745000Medicaid