Provider Demographics
NPI:1578519823
Name:HERTA, NANCY L (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:L
Last Name:HERTA
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 1:212 S SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1548
Mailing Address - Country:US
Mailing Address - Phone:231-924-3300
Mailing Address - Fax:
Practice Address - Street 1:212 S SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1548
Practice Address - Country:US
Practice Address - Phone:231-924-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068990207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0330372Medicaid
MI0M21440038OtherMEDICARE PLUS BLUE
MI200000002109OtherPHP FAMILYCARE
MI1021345OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI1578519823Medicaid
MI5305216OtherAETNA
MI1603303722OtherBCBS/BCN
MI1021345OtherMCLAREN HEALTH ADVANTAGE
MI1021345OtherMCLAREN HEALTH PLAN-MEDICAID
MI200000002109OtherPHP
MIG35257Medicare UPIN
MI5305216OtherAETNA