Basic Information
| Provider Information | |||||||||
| NPI: | 1265989925 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIVIA MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | CENTER FOR PELVIC PAIN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 130 LUBRANO DR | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105731436 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2016 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLANCY | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5719826636 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.