Basic Information
Provider Information | |||||||||
NPI: | 1154961316 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIVIA MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 950 N GLEBE RD STE 700 | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON | ||||||||
State: | VA | ||||||||
PostalCode: | 222034173 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5713668850 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 24560 SOUTHPOINT DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | ALDIE | ||||||||
State: | VA | ||||||||
PostalCode: | 201053505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3156010174 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2020 | ||||||||
LastUpdateDate: | 03/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IVESS | ||||||||
AuthorizedOfficialFirstName: | COURTNEY | ||||||||
AuthorizedOfficialMiddleName: | AINSWORTH | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR, CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 5713668831 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7442750011 | 01 | VA | MEDICARE DME | OTHER |