MEDICARE: GINA TERESE CIACCIA D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036.090016	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821231549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA TERESE CIACCIA D.O.

Provider Business Mailing Address
First Line	:	3259 S WELLS ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3619
Country	:	US
Telephone Number	:	312-225-5785
Fax Number	:	312-225-6103

Provider Business Practice Location Address
First Line	:	3259 S WELLS ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3619
Country	:	US
Telephone Number	:	312-225-5785
Fax Number	:	312-225-6103

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2009
Last Update Date	:	12/27/2021

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