Basic Information
| Provider Information | |||||||||
| NPI: | 1770212482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAYO CLINIC HEALTH SYSTEM-SOUTHWEST MINNESOTA REGION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 CITY WEST PKWY | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443248 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 MARSH ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560014752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076254031 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2022 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | PAUL | ||||||||
| AuthorizedOfficialFirstName: | TRAVIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL CHAIR ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5075942646 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.