Provider Demographics
NPI:1164407730
Name:TRIVAX, GEOFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:
Last Name:TRIVAX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28625 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 213
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1828
Mailing Address - Country:US
Mailing Address - Phone:248-354-9666
Mailing Address - Fax:248-354-3653
Practice Address - Street 1:28625 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 213
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1828
Practice Address - Country:US
Practice Address - Phone:248-354-9666
Practice Address - Fax:248-354-3653
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031978207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F314390OtherBLUE SHIELD
MI110169407OtherRR MEDICARE
MI103419OtherGREAT LAKES HEALTH PLAN
MI1164407730Medicaid
MI0635303OtherBCBS INDIVIDUAL
MIB0531OtherM'CARE
MI103419OtherGREAT LAKES HEALTH PLAN
MI0M96210022Medicare PIN