Healthcare Provider Details

I. General information

NPI: 1013313857
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 YORKTOWN DR
FAYETTEVILLE GA
30214-1578
US

IV. Provider business mailing address

950 N GLEBE RD STE 700
ARLINGTON VA
22203-4173
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-4285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JEANNETTE WOOD
Title or Position: VP REVENUE CYCLE MANAGER
Credential:
Phone: 301-672-2645