Basic Information
| Provider Information | |||||||||
| NPI: | 1114960978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHORTKOFF | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | SHADER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT OF ANESTH UNIV OF UTAH 30 NORTH 1900 E | ||||||||
| Address2: | ROOM 3C444 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015816393 | ||||||||
| FaxNumber: | 8015814367 | ||||||||
| Practice Location | |||||||||
| Address1: | DEPT OF ANESTH UNIV OF UTAH 30 NORTH 1900 E | ||||||||
| Address2: | ROOM 3C444 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015816393 | ||||||||
| FaxNumber: | 8015814367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 6801106 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G653710 | 05 | CA | MEDICAID |