Basic Information
| Provider Information | |||||||||
| NPI: | 1215040506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MMG 1PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29992 NORTHWESTERN HWY STE C | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488511430 | ||||||||
| FaxNumber: | 2488515182 | ||||||||
| Practice Location | |||||||||
| Address1: | 28625 NORTHWESTERN HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480348351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483540730 | ||||||||
| FaxNumber: | 2483541652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | TRIVAX | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2483549666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110F375070 | 01 | MI | BLUE SHIELD | OTHER |