Provider Demographics
NPI:1356576896
Name:MAYO CLINIC HEALTH SYSTEM-SOUTHWEST WISCONSIN REGION, INC.
Entity type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM-SOUTHWEST WISCONSIN REGION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BORTNEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-5270
Mailing Address - Street 1:PO BOX 4102
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54602-4102
Mailing Address - Country:US
Mailing Address - Phone:608-392-3988
Mailing Address - Fax:608-392-9180
Practice Address - Street 1:1303 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-8927
Practice Address - Country:US
Practice Address - Phone:608-526-1566
Practice Address - Fax:608-526-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI893042333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120399OtherPK
WI0741920008Medicare NSC