Provider Demographics
NPI:1396832606
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-ALBERT LEA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIR ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-422-5678
Mailing Address - Street 1:404 W FOUNTAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2437
Mailing Address - Country:US
Mailing Address - Phone:507-373-2384
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2437
Practice Address - Country:US
Practice Address - Phone:507-373-2384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330838332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0477370002Medicare NSC
MN4B244VIOtherBCBS
MN716545500Medicaid