Provider Demographics
NPI:1154550911
Name:HERNANDEZ, MAURILIO (MD)
Entity type:Individual
Prefix:DR
First Name:MAURILIO
Middle Name:
Last Name:HERNANDEZ
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 1:1834 S CEDAR ST
Mailing Address - Street 2:STE A
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-9779
Mailing Address - Country:US
Mailing Address - Phone:586-727-2761
Mailing Address - Fax:586-727-3120
Practice Address - Street 1:1834 S CEDAR ST STE A
Practice Address - Street 2:
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-9779
Practice Address - Country:US
Practice Address - Phone:810-721-0000
Practice Address - Fax:810-721-0003
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301095103207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154550911Medicaid
MI1235131137OtherBCBSM - BRONSON
MI1235131137OtherBCBSM - BRONSON