MEDICARE: PRIVIA MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1104688852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIVIA MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	950 N GLEBE RD STE 700
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22203-4173
Country	:	US
Telephone Number	:	571-982-6636
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 DEFENSE HWY STE 112
Second Line	:
City	:	ANNAPOLIS
State	:	MD
Zip	:	21401-7015
Country	:	US
Telephone Number	:	410-518-9808
Fax Number	:

Authorized Official
Title or Position	:	ENROLLMENT MANAGER
Name	:	MARIA GABBAI
Credential	:
Telephone Number	:	610-530-4363

Provider Enumeration Date	:	01/29/2024
Last Update Date	:	01/29/2024

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