Provider Demographics
NPI:1285740225
Name:GRIMAUD-CHILSON, REBECCA (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:GRIMAUD-CHILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KIM AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-9101
Mailing Address - Country:US
Mailing Address - Phone:570-836-4400
Mailing Address - Fax:570-836-4440
Practice Address - Street 1:1 KIM AVE STE 4
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-9101
Practice Address - Country:US
Practice Address - Phone:570-836-4400
Practice Address - Fax:570-836-4440
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419150208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA378679000Medicaid
PA378679000Medicaid
370002175Medicare ID - Type Unspecified