Provider Demographics
NPI:1467909036
Name:PRIVIA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PRIVIA MEDICAL GROUP, LLC
Other - Org Name:VIRGINIA FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLANCY
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:
Mailing Address - Fax:
Practice Address - Street 1:9401 LEE HWY
Practice Address - Street 2:SUITE 400
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-1849
Practice Address - Country:US
Practice Address - Phone:703-383-4836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7442750002Medicare NSC