Provider Demographics
NPI:1285873430
Name:MMG 1 PC
Entity type:Organization
Organization Name:MMG 1 PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TRIVAX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-354-9666
Mailing Address - Street 1:29992 NORTHWESTERN HWY STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3292
Mailing Address - Country:US
Mailing Address - Phone:248-851-1430
Mailing Address - Fax:248-851-5182
Practice Address - Street 1:32255 NORTHWESTERN HWY STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1573
Practice Address - Country:US
Practice Address - Phone:248-945-0000
Practice Address - Fax:248-945-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F381060OtherBLUE CARE NETWORK