Provider Demographics
NPI:1124002498
Name:BUCCALO, GINA L (MD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:L
Last Name:BUCCALO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GINA
Other - Middle Name:L
Other - Last Name:ZILINICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1135 W UNIVERSITY DR STE 225
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1890
Mailing Address - Country:US
Mailing Address - Phone:248-824-2570
Mailing Address - Fax:
Practice Address - Street 1:1135 W UNIVERSITY DR STE 225
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1890
Practice Address - Country:US
Practice Address - Phone:248-824-2570
Practice Address - Fax:248-824-2571
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB48763OtherHAP
MI4991906Medicaid
MI700E012740OtherBCBSM GROUP NUMBER
MI104449OtherCARE-PREFERRED CHOICES
MI0630154OtherBCBSM INDIVIDUAL PIN
MA4619672OtherAETNA ID NUMBER
MIB48763OtherHAP
MIN40170098Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
B48763Medicare UPIN