Basic Information
| Provider Information | |||||||||
| NPI: | 1992463210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGYO | ||||||||
| FirstName: | SAMUEL JR | ||||||||
| MiddleName: | BOBBIO | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25949 N ARROWHEAD DR | ||||||||
| Address2: | |||||||||
| City: | MUNDELEIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600604063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2247155927 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1845 GRANDSTAND PL | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601236603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476950484 | ||||||||
| FaxNumber: | 8476951265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2021 | ||||||||
| LastUpdateDate: | 01/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 820429079 | 01 | IL | BLUECROSS BLUESHIELD | OTHER | XOF820429079 | 01 | IL | BLUECROSS BLUE SHIELD | OTHER |