Provider Demographics
NPI:1225689698
Name:PRIVIA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PRIVIA MEDICAL GROUP, LLC
Other - Org Name:MOUNT VERNON INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:AINSWORTH
Authorized Official - Last Name:IVESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-366-8831
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:
Practice Address - Street 1:6128 BRANDON AVE STE 201
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2693
Practice Address - Country:US
Practice Address - Phone:571-366-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7442750010OtherMEDICARE DME