Individual
EDWARD JOHN BANTAMOI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2502 S. ASHLAND AVE., GREEN BAY, WI 54304
(920) 496-4700
Mailing address
PO BOX 19070, GREEN BAY, WI 54307-9070
(920) 496-4700
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
48796
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
34814900
—
WI
Enumeration date
07/13/2006
Last updated
09/18/2017
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