Organization
MMG 1 PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GEOFFREY A TRIVAX MD (PRESIDENT)
(313) 538-3099
Entity
Organization
Contact information
Practice address
28625 NORTHWESTERN HWY, SUITE 213, SOUTHFIELD, MI 48034-1828
(248) 354-9666
(248) 354-3653
Mailing address
29992 NORTHWESTERN HWY STE C, FARMINGTON HILLS, MI 48334-3292
(248) 851-1430
(248) 851-5182
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
500F318990
BLUE SHIELD GROUP
MI
Enumeration date
07/19/2006
Last updated
05/24/2021
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