Provider Demographics
NPI:1356907273
Name:PRIVIA MEDICAL GROUP OF GEORGIA LLC
Entity type:Organization
Organization Name:PRIVIA MEDICAL GROUP OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
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:571-366-8845
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:571-366-8850
Mailing Address - Fax:
Practice Address - Street 1:1326 EISENHOWER DR BLDG 1
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3928
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:2019-05-16
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7787550001OtherMEDICARE DME