Healthcare Provider Details

I. General information

NPI: 1154356517
Provider Name (Legal Business Name): MMG 1PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31500 TELEGRAPH RD SUITE 100
BINGHAM FARMS MI
48025-4367
US

IV. Provider business mailing address

29992 NORTHWESTERN HWY STE C
FARMINGTON HILLS MI
48334-3292
US

V. Phone/Fax

Practice location:
  • Phone: 248-723-5880
  • Fax: 248-723-5889
Mailing address:
  • Phone: 248-851-1430
  • Fax: 248-851-5182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GEOFFREY A TRIVAX
Title or Position: PRESIDENT
Credential: MD
Phone: 313-538-3099