Provider Demographics
NPI:1235141664
Name:CHILSON, DALE R (DO)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:R
Last Name:CHILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1512
Mailing Address - Country:US
Mailing Address - Phone:815-224-3040
Mailing Address - Fax:815-224-4327
Practice Address - Street 1:4040 PROGRESS BLVD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1124
Practice Address - Country:US
Practice Address - Phone:815-224-3040
Practice Address - Fax:815-224-4327
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096113207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096113Medicaid
IL036096113Medicaid