Healthcare Provider Details

I. General information

NPI: 1710953666
Provider Name (Legal Business Name): VIJIL K RAHULAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2885 SANFORD AVE SW SUITE NO. 18083
GRANDVILLE MI
49418-1342
US

IV. Provider business mailing address

2885 SANFORD AVE SW SUITE NO. 18083
GRANDVILLE MI
49418-1342
US

V. Phone/Fax

Practice location:
  • Phone: 810-982-7243
  • Fax:
Mailing address:
  • Phone: 810-982-7243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4301078860
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4301078860
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301078860
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: