Healthcare Provider Details

I. General information

NPI: 1669466801
Provider Name (Legal Business Name): UMESH P GOSWAMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 PEARSON DR
GENOA IL
60135-1355
US

IV. Provider business mailing address

599 PEARSON DR
GENOA IL
60135-1355
US

V. Phone/Fax

Practice location:
  • Phone: 815-784-6437
  • Fax: 815-784-3933
Mailing address:
  • Phone: 815-784-6437
  • Fax: 815-784-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036058246
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: