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SCH240166-00 MAYO CLINIC HEALTH SYSTEM-FAIRMONT (Terminated)
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Main Details
Name
MAYO CLINIC HEALTH SYSTEM-FAIRMONT
Subdivision Name
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH240166-00
Medicare Provider Number
240166
Additional Details
Current Program Status
Terminated
Registration Date
4/12/2021
Participating Start Date
7/1/2021
Participating Approval Date
4/27/2021
Last Recertification Date
8/30/2023
Termination Date
Termination Reason
7/1/2024
DSH percentage below statutory minimum
Contacts
Authorizing Official
Mayo Clinic
Travis C. Paul, Regional Chair of Administration SWMN
(608) 392-9716
Primary Contact
Mayo Clinic
Alicia Buda, Operations Manager
(507) 293-3251
Addresses
Street Address
800 MEDICAL CENTER DRIVE
FAIRMONT, MN 56031
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating Start Date 10/1/2019, Termination Date 10/1/2020, Reinstatement 7/1/2021
04/13/2021
April 2025
April 2025
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