Provider Demographics
NPI:1174509046
Name:MAYO CLINIC HEALTH SYSTEM-SOUTHWEST WISCONSIN REGION, INC.
Entity Type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM-SOUTHWEST WISCONSIN REGION, INC.
Other - Org Name:MAYO CLINIC HEALTH SYSTEM SKEMP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANICIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BORTNEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-5270
Mailing Address - Street 1:PO BOX 083268
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60691-0268
Mailing Address - Country:US
Mailing Address - Phone:608-392-9710
Mailing Address - Fax:608-392-9429
Practice Address - Street 1:800 WEST AVE S STE 101
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8806
Practice Address - Country:US
Practice Address - Phone:608-392-9855
Practice Address - Fax:608-392-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7132333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0741920001Medicare NSC