Provider Demographics
NPI:1821066499
Name:MAYO CLINIC HEALTH SYSTEM-FAIRMONT
Entity Type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM-FAIRMONT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
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 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4575
Mailing Address - Country:US
Mailing Address - Phone:507-238-8100
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330764282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1628HFAOtherBLUE CROSS BLUE SHIELD
MN1628HFAOtherBLUE CROSS BLUE SHIELD
MN259845100Medicaid
MN259845100Medicaid
IA0928473Medicaid