Healthcare Provider Details

I. General information

NPI: 1649047762
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7811 MONTROSE RD STE 340
POTOMAC MD
20854-3359
US

IV. Provider business mailing address

PO BOX 13050
BELFAST ME
04915-4021
US

V. Phone/Fax

Practice location:
  • Phone: 301-588-7888
  • Fax: 301-588-3419
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACEY J BAUGHEY
Title or Position: AVP
Credential:
Phone: 267-981-6519