Basic Information
| Provider Information | |||||||||
| NPI: | 1083079099 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYO CLINIC ARIZONA | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | MAYO CLINIC STORE - PHOENIX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 2ND ST SW SUITE 1-18 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559023026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072843390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5881 E. MAYO BLVD | ||||||||
| Address2: | #3-105 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850544504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803018000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2015 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | FROISLAND | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4803018940 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.