MEDICARE: ERMITA BORT MD

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	261QP2300X	Primary Care Clinic/Center	575633-1205	UT
2	208M00000X	Hospitalist Physician	5756331-1205	UT

General Provider Information

NPI Number	:	1649475120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERMITA BORT MD

Provider Business Mailing Address
First Line	:	2055 VILLAGE POINT WAY
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-2681
Country	:	US
Telephone Number	:	801-318-2894
Fax Number	:	801-944-3729

Provider Business Practice Location Address
First Line	:	2055 VILLAGE POINT WAY
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-2681
Country	:	US
Telephone Number	:	801-318-2894
Fax Number	:	801-944-3729

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

Provider Enumeration Date	:	06/15/2007
Last Update Date	:	04/03/2013

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