Provider Demographics
NPI:1972700607
Name:MMG 1PC
Entity type:Organization
Organization Name:MMG 1PC
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 1:26400 W 12 MILE RD
Practice Address - Street 2:SUITE 25
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1700
Practice Address - Country:US
Practice Address - Phone:248-864-4444
Practice Address - Fax:248-864-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30044OtherBLUE SHIELD
MI=========OtherFEIN
MI30044OtherBLUE SHIELD