Basic Information
| Provider Information | |||||||||
| NPI: | 1881714723 | ||||||||
| 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: | 28000 JOY RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481504137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345138050 | ||||||||
| FaxNumber: | 7345136357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2007 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | TORRES | ||||||||
| AuthorizedOfficialFirstName: | ALEX | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7036844581 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110163653 | 01 | GA | RAILROAD MEDICARE | OTHER | 343393810 | 05 | MI | MEDICAID | 700F314390 | 01 | MI | BCBS MI | OTHER |