Provider Demographics
NPI:1790848992
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-AUSTIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORDRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-594-2646
Mailing Address - Street 1:1000 1ST DR NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2941
Mailing Address - Country:US
Mailing Address - Phone:507-434-1422
Mailing Address - Fax:507-422-1035
Practice Address - Street 1:1000 1ST DR NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2941
Practice Address - Country:US
Practice Address - Phone:507-434-1422
Practice Address - Fax:507-422-1035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYO CLINIC HEALTH SYSTEM-ALBERT LEA AND AUSTIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-18
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2640853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2418906OtherNCPDP#
MN387024300Medicaid
2418906OtherNCPDP#