NPIMap

Individual provider Active NPI

Edward John Bantamoi, MD

  • Family Medicine Physician
  • Green Bay, WI
National Provider Identifier
1457376758
Registry record updated Sep 18, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
48796 Issued in WI
Practice address
2502 S. Ashland Ave.
Green Bay, WI 54304
Phone
(920) 496-4700
NPI assigned
Jul 13, 2006
Last updated
Sep 18, 2017By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 18, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 48796 WI Primary

Addresses

Primary practice location

2502 S. Ashland Ave.
Green Bay, WI 54304

Mailing address

PO Box 19070
Green Bay, WI 54307-9070
Phone (920) 496-4700

Other identifiers 1

IdentifierTypeStateIssuer
34814900MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20060208000524 WI Practitioner - Family Practice 5395730097 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 1996
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

2502 S Ashland Ave
Green Bay, WI 54304-5252
Phone (920) 496-4700

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
94.81 of 100Reported as apm
Quality
85.98
Promoting interoperability
100
Improvement activities
40

Procedures performed for Medicare patients

ProcedureNumber of procedures
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
St Vincent Hospital-Hospital Sisters-Third Order of St Francis CurrentSince Aug 1, 2009 Accepting new patients
St Vincent Hospital-Hospital Sisters-Third Order of St Francis Family Medicine CurrentSince Aug 1, 2009 Accepting new patients
Prevea Clinic, Inc. Family Medicine CurrentSince Dec 1, 2005 Accepting new patients
Prevea Clinic, Inc. Family Medicine CurrentSince Dec 1, 2005 Accepting new patients
Prevea Regional Services, Inc. Family Medicine Past Accepting new patients

Locations

1726 Shawano Ave
Green Bay, WI 54303
Phone (920) 432-6016

2502 S Ashland Ave
Green Bay, WI 54304
Phone (920) 496-4750

835 S Van Buren St
Green Bay, WI 54301
Phone (888) 901-7246

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152748800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1505692800000",
    "number": "1457376758",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 19070",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543079070",
            "telephone_number": "920-496-4700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2502 S. ASHLAND AVE.",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "54304",
            "telephone_number": "920-496-4700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BANTAMOI",
        "first_name": "EDWARD",
        "middle_name": "JOHN",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-13",
        "last_updated": "2017-09-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "48796",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "34814900",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Green Bay, WI

Sources for this page

Verify at the official NPI Registry.