Healthcare Provider Details

I. General information

NPI: 1275395865
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 PROSPERITY DR STE 100
SILVER SPRING MD
20904-1647
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 301-681-6730
  • Fax:
Mailing address:
  • Phone: 571-982-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARIA GABBAI
Title or Position: ENROLLMENT MANAGER
Credential:
Phone: 484-569-9066