Provider Demographics
NPI:1699940890
Name:MAGPAYO, PRUDENCIO BIGORNIA JR (PT)
Entity type:Individual
Prefix:
First Name:PRUDENCIO
Middle Name:BIGORNIA
Last Name:MAGPAYO
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:JOJO
Other - Middle Name:
Other - Last Name:MAGPAYO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5333 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1948
Mailing Address - Country:US
Mailing Address - Phone:708-234-2028
Mailing Address - Fax:
Practice Address - Street 1:6801 HIGH GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7585
Practice Address - Country:US
Practice Address - Phone:630-920-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR02284Medicare PIN