Basic Information
| Provider Information | |||||||||
| NPI: | 1376110858 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIVIA MEDICAL GROUP TENNESSEE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N GLEBE RD STE 700 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222034173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5719826636 | ||||||||
| FaxNumber: | 2406961353 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 VANTAGE WAY STE C240 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372281580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5719826636 | ||||||||
| FaxNumber: | 2406961353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2021 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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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: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.