MEDICARE: NEUROMONITORING SERVICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	036-061013	IL

General Provider Information

NPI Number	:	1467583955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROMONITORING SERVICE LLC

Provider Business Mailing Address
First Line	:	1604 VISA DR STE 1
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-2195
Country	:	US
Telephone Number	:	309-454-1100
Fax Number	:	309-218-1415

Provider Business Practice Location Address
First Line	:	1604 VISA DR STE 1
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-2195
Country	:	US
Telephone Number	:	309-454-1100
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	PANNA U GOSWAMI
Credential	:	MD
Telephone Number	:	309-846-4716

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	08/30/2023

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