Organization
MMG 1PC
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
31500 TELEGRAPH RD, SUITE 100, BINGHAM FARMS, MI 48025-4367
(248) 723-5880
(248) 723-5889
Mailing address
29992 NORTHWESTERN HWY, 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
—
110F301040
BLUE SHIELD GROUP
MI
01
—
CG6180
MEDICARE ID TYPE UNSPECIFIED
MI
Enumeration date
07/12/2006
Last updated
09/20/2018
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