1023043486 NPI number — MMG 1 PC

Table of content: (NPI 1023043486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023043486 NPI number — MMG 1 PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMG 1 PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INTERNAL MEDICINE SPECIALISTS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023043486
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29992 NORTHWESTERN HWY STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-3292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-851-1430
Provider Business Mailing Address Fax Number:
248-851-5182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5821 W MAPLE RD
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48322-2275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-855-0407
Provider Business Practice Location Address Fax Number:
248-855-1323
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

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:
313-538-3099

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110F375900 . This is a "BLUE SHIELD GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CG6179 . This is a "MEDICARE ID TYPE UNSPECIFIED" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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