Provider Demographics
NPI:1467583955
Name:NEUROMONITORING SERVICE LLC
Entity Type:Organization
Organization Name:NEUROMONITORING SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
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:309-846-4716
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:309-454-1100
Mailing Address - Fax:309-218-1415
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:309-454-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-061013208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
216076Medicare PIN