Healthcare Provider Details

I. General information

NPI: 1811715436
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11119 ROCKVILLE PIKE STE 500
ROCKVILLE MD
20852-3157
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 240-630-2188
  • Fax: 301-603-2294
Mailing address:
  • Phone: 484-228-1065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLISON HENNESSEY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 304-282-4929