Basic Information
| Provider Information | |||||||||
| NPI: | 1669131173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGLIVI | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | SERGIO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2512 N SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474041840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123697118 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2455 N TAMARACK TRL | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474081294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123367060 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2021 | ||||||||
| LastUpdateDate: | 12/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06005827A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.