Provider Demographics
NPI:1871587303
Name:GOSWAMI, PANNA U (MD)
Entity type:Individual
Prefix:DR
First Name:PANNA
Middle Name:U
Last Name:GOSWAMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1604 VISA DR STE 1
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2195
Mailing Address - Country:US
Mailing Address - Phone:815-762-2535
Mailing Address - Fax:815-758-5144
Practice Address - Street 1:1604 VISA DR STE 1
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2195
Practice Address - Country:US
Practice Address - Phone:815-846-4716
Practice Address - Fax:309-323-0442
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061013208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-061013Medicaid
ILC45695Medicare UPIN
IL036-061013Medicaid