Provider Demographics
NPI:1497730865
Name:EBBEN, JAMES ROBERT (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:EBBEN
Suffix:
Gender:M
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: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:920-445-7226
Mailing Address - Fax:920-445-7238
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:2005-12-08
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29793207Q00000X
WI29793-20207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
354601OtherAMERICAN BOARD OF FAMILY MEDICINE-SPORTS MEDICINE
WI29793OtherLICENSE
E91927Medicare UPIN
WI075100004Medicare Oscar/Certification