Provider Demographics
NPI:1033393889
Name:UMESH P. GOSWAMI, MD SC
Entity Type:Organization
Organization Name:UMESH P. GOSWAMI, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:UMESH
Authorized Official - Middle Name:P
Authorized Official - Last Name:GOSWAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-758-5100
Mailing Address - Street 1:625 BETHANY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4908
Mailing Address - Country:US
Mailing Address - Phone:815-758-5100
Mailing Address - Fax:815-758-5144
Practice Address - Street 1:625 BETHANY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4908
Practice Address - Country:US
Practice Address - Phone:815-758-5100
Practice Address - Fax:815-758-5144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042005119261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21609266OtherBCBS
IL036058246Medicaid
IL966730Medicare PIN
ILC44300Medicare UPIN