Provider Demographics
NPI:1548283435
Name:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Entity type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:SCHAUS
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-5270
Mailing Address - Street 1:PO BOX 860092
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0092
Mailing Address - Country:US
Mailing Address - Phone:715-838-5856
Mailing Address - Fax:
Practice Address - Street 1:1707 WESTGATE RD STE 1
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-4964
Practice Address - Country:US
Practice Address - Phone:715-838-5861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYO CLINIC HEALTH SYSTEM-NORTHWEST WISCONSIN REGION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI85303336L0003X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33184700Medicaid
51 21013OtherNCPDP
BM9555357OtherDEA
BM9555357OtherDEA
0408270002Medicare Oscar/Certification