Basic Information
| Provider Information | |||||||||
| NPI: | 1174566095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRIVAX | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | ELIJAH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29992 NORTHWESTERN HWY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488511430 | ||||||||
| FaxNumber: | 2488515182 | ||||||||
| Practice Location | |||||||||
| Address1: | 31500 TELEGRAPH RD | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480254367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485944913 | ||||||||
| FaxNumber: | 2485944928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301081886 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 4301081886 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1174566095 | 05 | MI | MEDICAID | 700H273300 | 01 | MI | BLUE SHIELD | OTHER |