Healthcare Provider Details

I. General information

NPI: 1710073382
Provider Name (Legal Business Name): ERNEST E ERTMOED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 CHURCHILL RD
SPRINGFIELD IL
62702-3493
US

IV. Provider business mailing address

1250 CHURCHILL RD
SPRINGFIELD IL
62702-3493
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-7556
  • Fax:
Mailing address:
  • Phone: 217-546-7556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036062213
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: