Healthcare Provider Details

I. General information

NPI: 1487267910
Provider Name (Legal Business Name): MAYO CLINIC HEALTH SYSTEM-SOUTHEAST MINNESOTA REGION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2437
US

IV. Provider business mailing address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2437
US

V. Phone/Fax

Practice location:
  • Phone: 507-373-2384
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: PRAVEEN MEKALA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 507-266-1557