Basic Information
| Provider Information | |||||||||
| NPI: | 1205582087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIVIA MEDICAL GROUP TENNESSEE LLC | ||||||||
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| OtherOrganizationName: | SPORTS ORTHO URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N GLEBE RD STE 700 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222034173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5719826636 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4998 CROSSINGS CIR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371220018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2022 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROLLER | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR/ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 7703125226 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.