Provider Demographics
NPI:1821231549
Name:CIACCIA, GINA TERESE (DO)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:TERESE
Last Name:CIACCIA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3259 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3619
Mailing Address - Country:US
Mailing Address - Phone:312-225-5785
Mailing Address - Fax:312-225-6103
Practice Address - Street 1:3259 S WELLS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3619
Practice Address - Country:US
Practice Address - Phone:312-225-5785
Practice Address - Fax:312-225-6103
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.090016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128663Medicaid
IL036128663Medicaid