Provider Demographics
NPI:1700852613
Name:CHILSON CLINIC PC
Entity Type:Organization
Organization Name:CHILSON CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CHILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-836-4400
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014661730001Medicaid
PA060343ULVMedicare ID - Type Unspecified
PA1014661730001Medicaid