Provider Demographics
NPI:1043220783
Name:PIPER, GINA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:MARIE
Last Name:PIPER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:BULF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:676 N SAINT CLAIR ST
Mailing Address - Street 2:STE 1500
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2995
Mailing Address - Country:US
Mailing Address - Phone:847-864-5200
Mailing Address - Fax:847-864-1231
Practice Address - Street 1:522 DEMPSTER AVE.
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202
Practice Address - Country:US
Practice Address - Phone:847-864-5200
Practice Address - Fax:847-864-1231
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
210209OtherMEDICARE GROUP
IL046008974Medicaid
7235044OtherAETNA
1636706OtherBCBS
IL8825444OtherMULTIPLAN
IL8825444OtherMULTIPLAN
210209OtherMEDICARE GROUP