Provider Demographics
NPI:1114788601
Name:PRIVIA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PRIVIA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GABBAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-530-4363
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:571-982-6636
Mailing Address - Fax:
Practice Address - Street 1:198 THOMAS JOHNSON DR STE 17
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4451
Practice Address - Country:US
Practice Address - Phone:301-718-9611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty