Basic Information
| Provider Information | |||||||||
| NPI: | 1104893080 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAYO CLINIC HOSPITAL-ROCHESTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072841937 | ||||||||
| FaxNumber: | 5072840986 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 NW 26TH ST | ||||||||
| Address2: | |||||||||
| City: | OWATONNA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550605503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074511120 | ||||||||
| FaxNumber: | 5074446287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5075383389 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAYO CLINIC HOSPITAL-ROCHESTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 324083 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 080847400 | 05 | MN | MEDICAID |