Organization
MMG 1PC
Active
Other names
PREMIER INTERNISTS
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GEOFFREY A TRIVAX M.D. (PRESIDENT)
(248) 354-9666
Entity
Organization
Contact information
Practice address
29201 TELEGRAPH RD, SUITE 404, SOUTHFIELD, MI 48034-1331
(248) 355-0880
(248) 355-9232
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
—
700F314390
BLUE SHIELD GROUP
MI
Enumeration date
08/14/2006
Last updated
09/20/2018
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