MEDICARE: DR. PANNA U GOSWAMI MD

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	036061013	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871587303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PANNA U GOSWAMI MD

Provider Business Mailing Address
First Line	:	1604 VISA DR STE 1
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-2195
Country	:	US
Telephone Number	:	815-762-2535
Fax Number	:	815-758-5144

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	:	815-846-4716
Fax Number	:	309-323-0442

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	06/01/2023

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Directions to “ DR. PANNA U GOSWAMI MD” Practice Location

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