Basic Information
| Provider Information | |||||||||
| NPI: | 1013042480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIVIA MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N GLEBE RD STE 700 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222034173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713668850 | ||||||||
| FaxNumber: | 2406961353 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 N GLEBE RD | ||||||||
| Address2: | SUITE 4000 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222031824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713668850 | ||||||||
| FaxNumber: | 8133156180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | JEFFRERY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRMAN & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5713668850 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.