Basic Information
| Provider Information | |||||||||
| NPI: | 1912933540 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MMG 1 PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MILLENIUM DIAGNOSTIC CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 32255 NORTHWESTERN HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483341573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489450000 | ||||||||
| FaxNumber: | 2489451819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 12/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TRIVAX | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2488511430 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 12/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RM1200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Magnetic Resonance Imaging (MRI) | 207UN0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CJ8411 | 01 | MI | MEDICARE ID TYPE UNSPECIFIED | OTHER | 700F314390 | 01 | MI | BLUE SHIELD GROUP | OTHER | CH5573 | 01 | MI | MEDICARE ID TYPE UNSPECIFIED | OTHER | DA4193 | 01 | MI | MEDICARE ID TYPE UNSPECIFIED | OTHER | DD1976 | 01 | MI | MEDICARE IS TYPE UNSPECIFIED | OTHER | CF9345 | 01 | MI | MEDICARE IS TYPE UNSPECIFIED | OTHER | 0M96210 | 01 | MI | MEDICARE PTAN | OTHER | 1912933540 | 05 | MI | MEDICAID | CG6178 | 01 | MI | MEDICARE ID TYPE UNSPECIFIED | OTHER |