Healthcare Provider Details

I. General information

NPI: 1861099541
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 GALLANT FOX LN STE 222
BOWIE MD
20715-4033
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 301-262-7800
  • Fax: 301-805-0782
Mailing address:
  • Phone: 571-982-6636
  • Fax: 240-696-1353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY AINSWORTH IVESS
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 571-366-8831