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General NPI Number Information
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NPI Number | 1164052189
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Entity Type | Organization
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Legal Business Name | PRIVIA MEDICAL GROUP OF GEORGIA LLC
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Dates
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Enumeration Date | 01/17/2020
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Last Update Date | 01/17/2020
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Provider Practice Location Address
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Address Line | 340 EISENHOWER DR STE 1200
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City | SAVANNAH
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State | GA
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Zip | 31406-2675
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Country | US
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Telephone | 912-443-4200
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Fax |
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Provider Business Mailing Address
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Address Line | 950 N GLEBE RD STE 700
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City | ARLINGTON
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State | VA
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Zip | 22203-4173
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ASSOCIATE DIRECTOR, CREDENTIALING
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Name | COURTNEY IVESS
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Credential |
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Telephone | 571-366-8831
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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