Provider Demographics
NPI:1629091004
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: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 860098
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0098
Mailing Address - Country:US
Mailing Address - Phone:715-597-3166
Mailing Address - Fax:
Practice Address - Street 1:13025 8TH ST STE 1
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:WI
Practice Address - Zip Code:54758-7634
Practice Address - Country:US
Practice Address - Phone:715-597-3166
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:2006-07-26
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7330333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
51 21645OtherNCPDP
BL3711810OtherDEA
WI33194100Medicaid
BL3711810OtherDEA