Healthcare Provider Details

I. General information

NPI: 1023982667
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2025
Last Update Date: 10/04/2025
Certification Date: 10/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17341 MELFORD BLVD STE L-M
BOWIE MD
20715-4457
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 301-776-8000
  • Fax:
Mailing address:
  • Phone: 800-973-1442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLISON HENNESSEY
Title or Position: VP, ENROLLMENT & CREDENTIALING
Credential:
Phone: 304-282-4929