Provider Demographics
NPI:1730664012
Name:PRIVIA CARE CENTER LLC
Entity Type:Organization
Organization Name:PRIVIA CARE CENTER LLC
Other - Org Name:
Other - Org Type:
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 4000
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1824
Mailing Address - Country:US
Mailing Address - Phone:157-198-2663
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL ST STE 409
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
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:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty