Provider Demographics
NPI:1306161187
Name:CHARLES R MEAD
Entity type:Organization
Organization Name:CHARLES R MEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-735-9550
Mailing Address - Street 1:1502 WOODLANE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2221
Mailing Address - Country:US
Mailing Address - Phone:651-735-9550
Mailing Address - Fax:651-735-9322
Practice Address - Street 1:1502 WOODLANE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2221
Practice Address - Country:US
Practice Address - Phone:651-735-9550
Practice Address - Fax:651-735-9322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric TechnicianGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN97365062201OtherPREFERREDONE
MN25841MEOtherBLUE CROSS BLUE SHIELD
MN568938300Medicaid
MN1932129905OtherMEDICA
MN1932129905OtherPREFERRED ONE
MN123023900Medicaid
MN0629830001Medicare NSC