Healthcare Provider Details

I. General information

NPI: 1790443943
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP TENNESSEE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 MEMORIAL BLVD SUITE D
MURFREESBORO TN
37129
US

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY ROLLER
Title or Position: ASSOCIATE DIRECTOR/ENROLLMENT
Credential:
Phone: 770-312-5226