Provider Demographics
NPI:1902260060
Name:EBBEN, BENJAMIN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JAMES
Last Name:EBBEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BEAU
Other - Middle Name:JAMES
Other - Last Name:EBBEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1970 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4125
Practice Address - Country:US
Practice Address - Phone:920-430-4888
Practice Address - Fax:920-430-4889
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0066037207XX0004X, 207XX0004X
WI67976-20207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery