Active NPI
MMG 1PC
- Internal Medicine Physician
- Southfield, MI
National Provider Identifier
1679586192
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- Legal business name
- MMG 1PC
- Practice address
- 29201 Telegraph Rd
Suite 404
Southfield, MI 48034-1331 - Phone
- (248) 355-0880
- Fax
- (248) 355-9232
- NPI assigned
- Aug 14, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Geoffrey A Trivax, M.D.
- Title
- President
- Phone
- (248) 354-9666
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | Primary |
Addresses
Primary practice location
29201 Telegraph Rd
Suite 404
Southfield, MI 48034-1331
Mailing address
29992 Northwestern Hwy Ste C
Farmington Hills, MI 48334-3292
Phone (248) 851-1430
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 700F314390 | Other | MI | BLUE SHIELD GROUP |
Other names 1
- PREMIER INTERNISTS
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MI
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031104000106 | MI | Part B Supplier - Clinic/Group Practice | 6103738638 |
Receives reassigned benefits from 30 practitioners 9 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Farmington Hills, MI |
Other NPIs on the same Medicare enrollment 9
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
National Provider Directory
National Provider DirectoryNPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1155513600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1537401600000",
"number": "1679586192",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "29992 NORTHWESTERN HWY STE C",
"city": "FARMINGTON HILLS",
"state": "MI",
"postal_code": "483343292",
"telephone_number": "248-851-1430",
"fax_number": "248-851-5182"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "29201 TELEGRAPH RD",
"address_2": "SUITE 404",
"city": "SOUTHFIELD",
"state": "MI",
"postal_code": "480341331",
"telephone_number": "248-355-0880",
"fax_number": "248-355-9232"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "MMG 1PC",
"organizational_subpart": "NO",
"enumeration_date": "2006-08-14",
"last_updated": "2018-09-20",
"status": "A",
"authorized_official_last_name": "TRIVAX",
"authorized_official_first_name": "GEOFFREY",
"authorized_official_middle_name": "A",
"authorized_official_title_or_position": "PRESIDENT",
"authorized_official_telephone_number": "248-354-9666",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "M.D."
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Internal Medicine",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE SHIELD GROUP",
"identifier": "700F314390",
"state": "MI"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "PREMIER INTERNISTS",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "PREMIER INTERNISTS",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Southfield, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.