Provider Demographics
NPI:1649475120
Name:BORT, ERMITA (MD)
Entity type:Individual
Prefix:
First Name:ERMITA
Middle Name:
Last Name:BORT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 VILLAGE POINT WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-2681
Mailing Address - Country:US
Mailing Address - Phone:801-318-2894
Mailing Address - Fax:801-944-3729
Practice Address - Street 1:2055 VILLAGE POINT WAY
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-2681
Practice Address - Country:US
Practice Address - Phone:801-318-2894
Practice Address - Fax:801-944-3729
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT575633-1205261QP2300X
UT5756331-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care