Healthcare Provider Details

I. General information

NPI: 1205855186
Provider Name (Legal Business Name): MMG 1PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7419 MIDDLEBELT RD SUITE 4
WEST BLOOMFIELD MI
48322-4182
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 248-855-2291
  • Fax: 248-855-4901
Mailing address:
  • Phone: 248-851-1430
  • Fax: 248-851-5182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily 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