1215103940 NPI number — MMG 1PC

Table of content: (NPI 1215103940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215103940 NPI number — MMG 1PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMG 1PC
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:
NORTHWEST INTERNAL MEDICINE
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:
1215103940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2018
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:
28625 NORTHWESTERN HWY
Provider Second Line Business Practice Location Address:
SUITE 213
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48034-1828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-354-9666
Provider Business Practice Location Address Fax Number:
248-354-3653
Provider Enumeration Date:
05/02/2008

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:
248-851-1430

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 700F322430 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700F322430 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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