Provider Demographics
NPI:1124156765
Name:MEAD AVENUE FAMILY PRACTICE, INC.
Entity type:Organization
Organization Name:MEAD AVENUE FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-664-4542
Mailing Address - Street 1:1086 MEAD AVE
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-8503
Mailing Address - Country:US
Mailing Address - Phone:814-664-4542
Mailing Address - Fax:814-664-4556
Practice Address - Street 1:1086 MEAD AVE
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-8503
Practice Address - Country:US
Practice Address - Phone:814-664-4542
Practice Address - Fax:814-664-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050434L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019472820001Medicaid
PADF6619OtherRAILROAD
PA108646Medicare PIN