Provider Demographics
NPI: | 1013042480 |
---|---|
Name: | PRIVIA MEDICAL GROUP, LLC |
Entity Type: | Organization |
Organization Name: | PRIVIA MEDICAL GROUP, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CHAIRMAN & CEO |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | JEFFRERY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BUTLER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 571-366-8850 |
Mailing Address - Street 1: | 950 N GLEBE RD STE 700 |
Mailing Address - Street 2: | |
Mailing Address - City: | ARLINGTON |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 22203-4173 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 571-366-8850 |
Mailing Address - Fax: | 240-696-1353 |
Practice Address - Street 1: | 950 N GLEBE RD |
Practice Address - Street 2: | SUITE 4000 |
Practice Address - City: | ARLINGTON |
Practice Address - State: | VA |
Practice Address - Zip Code: | 22203-1824 |
Practice Address - Country: | US |
Practice Address - Phone: | 571-366-8850 |
Practice Address - Fax: | 813-315-6180 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-02-23 |
Last Update Date: | 2020-03-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207RS0012X | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207VG0400X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | Group - Multi-Specialty |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | Group - Multi-Specialty |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
DC | G01961 | Medicare Oscar/Certification | |
VA | 7442750001 | Medicare NSC |