Provider Demographics
NPI:1427008986
Name:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Entity Type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Other - Org Name:MAYO CLINIC DIALYSIS-MENOMONIE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-5270
Mailing Address - Street 1:1221 WHIPPLE ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-5270
Mailing Address - Country:US
Mailing Address - Phone:715-838-5270
Mailing Address - Fax:
Practice Address - Street 1:407 21ST ST SE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2217
Practice Address - Country:US
Practice Address - Phone:715-838-5270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-12
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1990261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11011800Medicaid
WI42064000Medicaid
WI11011800Medicaid