MEDICARE: PONDVILLE MEDICAL ASSOCIATES, LLC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1477963460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONDVILLE MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	31 PINE ST
Second Line	:
City	:	NORFOLK
State	:	MA
Zip	:	02056-1642
Country	:	US
Telephone Number	:	508-660-2241
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 PINE ST
Second Line	:
City	:	NORFOLK
State	:	MA
Zip	:	02056-1642
Country	:	US
Telephone Number	:	508-623-3700
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RIAD MORTADA
Credential	:	MD
Telephone Number	:	508-623-3700

Provider Enumeration Date	:	04/30/2014
Last Update Date	:	01/05/2023

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