NPIMap

Individual provider Active NPI

Koti R Mannem, MD

  • Psychiatry Physician
  • Green Bay, WI
National Provider Identifier
1720188717
Registry record updated Mar 17, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
24001 Issued in WI
Practice address
3150 Gershwin Drive
Green Bay, WI 54311-5859
Phone
(920) 391-4700
Fax
(920) 391-4870
NPI assigned
Sep 22, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 17, 2025

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X 24001 WI Primary

Addresses

Primary practice location

3150 Gershwin Drive
Green Bay, WI 54311-5859

Mailing address

3150 Gershwin Drive
Green Bay, WI 54311-5859
Phone (920) 391-4700

Other identifiers 1

IdentifierTypeStateIssuer
1720188717MedicaidWI

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
I20041218000041 WI Practitioner - Psychiatry 7911964200 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Psychiatry
Education
Other, 1974
Medicare assignment
May accept Medicare assignment
Telehealth
Offers telehealth services
Group practices
County of BrownGroup PAC ID 1355435900, 16 clinicians
Oneida CountyGroup PAC ID 0345306403, 4 clinicians

Practice addresses (Care Compare)

3150 Gershwin Dr
Green Bay, WI 54311-4328
Phone (920) 391-4700

705 E Timber Dr
Rhinelander, WI 54501-2859
Phone (715) 362-7463

Hospital & facility affiliations

  • Aspirus Rhinelander Hospital Hospital, Rhinelander, WI, CCN 520019

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
24001WIMDPsychiatry Physician

Practice roles

OrganizationSpecialtyStatusNew patients
County of Brown Psychiatry CurrentSince Jan 1, 2010 Accepting new patients
County of Brown Current Accepting new patients
Aurora Counseling Centers Employee Support Systems, Inc. CurrentSince Jan 12, 2020 Accepting new patients
County of Brown CurrentSince Jan 1, 2010 Accepting new patients
Counseling & Development Center CurrentSince Jun 22, 2016 Accepting new patients
Oneida County CurrentSince Jan 1, 2025 Accepting new patients
The Human Service Center CurrentSince Mar 10, 2008 Accepting new patients
Foundations Health and Wholeness Inc PastSince Dec 1, 1998 Accepting new patients
County of Brown Past Accepting new patients

Locations

3150 Gershwin Dr
Green Bay, WI 54311
Phone (920) 391-4700

406 Technology Dr E
Ste B
Menomonie, WI 54751
Phone (715) 235-1839

171 Chestnut St
Phillips, WI 54555
Phone (715) 339-3048

705 E Timber Dr
Rhinelander, WI 54501
Phone (715) 362-7463

Organizations & group practices 9

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

Hospital & facility affiliations 16

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

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1158883200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1742169600000",
    "number": "1720188717",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3150 GERSHWIN DRIVE",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543115859",
            "telephone_number": "920-391-4700",
            "fax_number": "920-391-4870"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3150 GERSHWIN DRIVE",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543115859",
            "telephone_number": "920-391-4700",
            "fax_number": "920-391-4870"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MANNEM",
        "first_name": "KOTI",
        "middle_name": "R",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-22",
        "last_updated": "2025-03-17",
        "certification_date": "2025-03-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "WI",
            "license": "24001",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1720188717",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Green Bay, WI

Sources for this page

Verify at the official NPI Registry.