Provider Demographics
NPI:1124207311
Name:UMESH P. GOSWAMI MD SC
Entity Type:Organization
Organization Name:UMESH P. GOSWAMI MD SC
Other - Org Name:PROGRESSIVE PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PANNA
Authorized Official - Middle Name:U
Authorized Official - Last Name:GOSWAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-762-2535
Mailing Address - Street 1:625 E. 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 E. 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:2007-10-24
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061013208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213624Medicare PIN