Healthcare Provider Details

I. General information

NPI: 1639891880
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10750 COLUMBIA PIKE
SILVER SPRING MD
20901-4402
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 410-304-3413
  • Fax: 410-304-3412
Mailing address:
  • Phone: 571-982-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACEY J BAUGHEY
Title or Position: AVP, CREDENTIALING & ENROLLMENT
Credential:
Phone: 267-981-6519