Provider Demographics
NPI:1629144407
Name:RIAD K. MORTADA, MD, PC
Entity Type:Organization
Organization Name:RIAD K. MORTADA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RIAD
Authorized Official - Middle Name:K
Authorized Official - Last Name:MORDATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-660-2241
Mailing Address - Street 1:420 MAIN ST
Mailing Address - Street 2:STE # 14
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-3753
Mailing Address - Country:US
Mailing Address - Phone:508-660-2241
Mailing Address - Fax:508-660-2914
Practice Address - Street 1:420 MAIN ST
Practice Address - Street 2:STE # 14
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-3753
Practice Address - Country:US
Practice Address - Phone:508-660-2241
Practice Address - Fax:508-660-2914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-25
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA645173OtherTUFTS HEALTH PLAN
MAM17091OtherBCBS
MA9784691Medicaid
MARR34OtherHARVARD PILGRIM
MA04-02110OtherUNITED HEALTHCARE
MAM17091OtherBCBS
MA=========00OtherNEIGHBORHOOD HEALTH