# MMG 1 PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1023037025
- **Authorized official:** DR. GEOFFREY A TRIVAX MD (PRESIDENT)
- **Authorized official phone:** (313) 538-3099

## Contact information

- **Practice address:** 28625 NORTHWESTERN HWY, SUITE 213, SOUTHFIELD, MI 48034-1828
- **Practice address phone:** (248) 354-9666
- **Practice address fax:** (248) 354-3653
- **Mailing address:** 29992 NORTHWESTERN HWY STE C, FARMINGTON HILLS, MI 48334-3292
- **Mailing address phone:** (248) 851-1430
- **Mailing address fax:** (248) 851-5182

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363L00000X | Nurse Practitioner | — | NULL | Yes |
| 363L00000X | Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 07/19/2006
- **Last updated:** 05/24/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 500F318990 | BLUE SHIELD GROUP | MI |