Provider Demographics
NPI:1932197324
Name:BRILLANTES, RAFAEL C (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:C
Last Name:BRILLANTES
Suffix:
Gender:M
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:PO BOX 891
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-0891
Mailing Address - Country:US
Mailing Address - Phone:517-788-6446
Mailing Address - Fax:517-788-9035
Practice Address - Street 1:426 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1235
Practice Address - Country:US
Practice Address - Phone:517-788-6446
Practice Address - Fax:517-788-9035
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032396207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4179588Medicaid
MI0420044OtherPHP
MIC1798OtherMCARE
MI1103842782OtherBCBS OF MICHIGAN
MI4179588Medicaid
MIOM90780Medicare ID - Type Unspecified