MEDICARE: DR. RONALD W MORTARA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	45935	MA

General Provider Information

NPI Number	:	1013937069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD W MORTARA M.D.

Provider Business Mailing Address
First Line	:	353 WOODWARD ST
Second Line	:
City	:	WABAN
State	:	MA
Zip	:	02468-2027
Country	:	US
Telephone Number	:	617-964-4341
Fax Number	:	617-964-1023

Provider Business Practice Location Address
First Line	:	353 WOODWARD ST
Second Line	:
City	:	WABAN
State	:	MA
Zip	:	02468-2027
Country	:	US
Telephone Number	:	617-964-4341
Fax Number	:	617-964-1023

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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