Basic Information
| Provider Information | |||||||||
| NPI: | 1225689698 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIVIA MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | MOUNT VERNON INTERNAL MEDICINE | ||||||||
| 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: | 5713668850 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6128 BRANDON AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221502693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713668850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2019 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | IVESS | ||||||||
| AuthorizedOfficialFirstName: | COURTNEY | ||||||||
| AuthorizedOfficialMiddleName: | AINSWORTH | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR, CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5713668831 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 7442750010 | 01 | VA | MEDICARE DME | OTHER |