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NPI Code Detail

MEDICARE: NICOLE LEIGH ERTL M.D.

MEDICARE: NICOLE LEIGH ERTL M.D.
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
1208000000XPediatrics Physician4301096897WI

General Provider Information

NPI Number : 1457664385
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE LEIGH ERTL M.D.
Provider Business Mailing Address
First Line : 877 FOREST HILL AVE SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49546-2380
Country : US
Telephone Number : 616-949-4465
Fax Number :
Provider Business Practice Location Address
First Line : 4410 REGENT ST
Second Line :
City : MADISON
State : WI
Zip : 53705-4901
Country : US
Telephone Number : 608-233-9746
Fax Number : 608-233-0026
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2010
Last Update Date : 12/08/2025

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