Healthcare Provider Details

I. General information

NPI: 1154961316
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24560 SOUTHPOINT DR STE 200
ALDIE VA
20105-3505
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 315-601-0174
  • Fax:
Mailing address:
  • Phone: 571-366-8850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY AINSWORTH IVESS
Title or Position: ASSOCIATE DIRECTOR, CREDENTIALING
Credential:
Phone: 571-366-8831