Healthcare Provider Details

I. General information

NPI: 1023043486
Provider Name (Legal Business Name): MMG 1 PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5821 W MAPLE RD SUITE 190
WEST BLOOMFIELD MI
48322-2275
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 248-855-0407
  • Fax: 248-855-1323
Mailing address:
  • Phone: 248-851-1430
  • Fax: 248-851-5182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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