Provider Demographics
NPI:1982639357
Name:MMG 1 PC
Entity Type:Organization
Organization Name:MMG 1 PC
Other - Org Name:MILLENIUM DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
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:313-538-3099
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:248-851-1434
Mailing Address - Fax:248-851-5182
Practice Address - Street 1:30840 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2552
Practice Address - Country:US
Practice Address - Phone:248-932-8725
Practice Address - Fax:248-932-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F319250OtherBLUE SHIELD GROUP
MICK4521OtherMEDICARE ID TYPE UNSPECIFIED
MI700F319250OtherBLUE SHIELD GROUP