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General NPI Number Information
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NPI Number | 1366458457
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Entity Type | Individual
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Provider Name | CYNTHIA MAE WILSON GRILLO DO
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Gender | Female
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Dates
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Enumeration Date | 07/31/2006
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Last Update Date | 02/01/2012
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Provider Practice Location Address
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Address Line | 100 SOUTH ST SUITE 102
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City | SOUTHBRIDGE
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State | MA
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Zip | 01550-4051
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Country | US
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Telephone | 508-764-3194
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Fax | 508-765-5458
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Provider Business Mailing Address
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Address Line | 100 SOUTH ST SUITE 102
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City | SOUTHBRIDGE
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State | MA
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Zip | 01550-4051
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Country | US
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Telephone | 508-764-3194
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Fax | 508-765-5458
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 152581
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License Number State | MA
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