Organization
MMG 1 PC
Active
Other names
INTERNAL MEDICINE SPECIALISTS
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GEOFFREY A TRIVAX MD (PRESIDENT)
(313) 538-3099
Entity
Organization
Contact information
Practice address
5821 W MAPLE RD, SUITE 190, WEST BLOOMFIELD, MI 48322-2275
(248) 855-0407
(248) 855-1323
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
207R00000X
Internal Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110F375900
BLUE SHIELD GROUP
MI
01
—
CG6179
MEDICARE ID TYPE UNSPECIFIED
MI
Enumeration date
07/12/2006
Last updated
05/24/2021
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