Provider Demographics
NPI:1467224667
Name:PRIVIA MEDICAL GROUP TENNESSEE LLC
Entity Type:Organization
Organization Name:PRIVIA MEDICAL GROUP TENNESSEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-312-5226
Mailing Address - Street 1:3715 NORTHSIDE PKWY NW STE 550
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2886
Mailing Address - Country:US
Mailing Address - Phone:770-312-5226
Mailing Address - Fax:
Practice Address - Street 1:6746 CHARLOTTE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-4204
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:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty