Basic Information
| Provider Information | |||||||||
| NPI: | 1043220783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PIPER | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BULF | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 676 N SAINT CLAIR ST | ||||||||
| Address2: | STE 1500 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478645200 | ||||||||
| FaxNumber: | 8478641231 | ||||||||
| Practice Location | |||||||||
| Address1: | 522 DEMPSTER AVE. | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478645200 | ||||||||
| FaxNumber: | 8478641231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046-008974 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 210209 | 01 | MEDICARE GROUP | OTHER | 046008974 | 05 | IL | MEDICAID | 7235044 | 01 | AETNA | OTHER | 1636706 | 01 | BCBS | OTHER | 8825444 | 01 | IL | MULTIPLAN | OTHER |