=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922810076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIVIA MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2025
-----------------------------------------------------
Last Update Date | 01/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 IRVING ST NW STE 218
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20010-2993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-855-9680
-----------------------------------------------------
Fax | 202-758-3074
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 N GLEBE RD STE 700
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22203-4173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-973-1442
-----------------------------------------------------
Fax | 571-982-6636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MARIA GABBAI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-530-4363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------