Privia Medical Group Tennessee LLC

Primary specialty

Sports Medicine (Orthopaedic Surgery) PhysicianTaxonomy code 207XX0005X

Legal business name

PRIVIA MEDICAL GROUP TENNESSEE LLC

Doing business as

Sports Ortho Urgent Care

Practice address

1114 N Main St Ste B
Shelbyville, TN 37160-2380

Phone

(571) 982-6636

NPI assigned

Nov 24, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mary Roller

Title

Associate Director/Enrollment

Phone

(770) 312-5226

Specialties & licenses 1

Addresses

Other names 1

• Sports Ortho Urgent Care Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1637712000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1657670400000",
    "number": "1427715440",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "950 N GLEBE RD STE 700",
            "city": "ARLINGTON",
            "state": "VA",
            "postal_code": "222034173",
            "telephone_number": "571-982-6636"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1114 N MAIN ST STE B",
            "city": "SHELBYVILLE",
            "state": "TN",
            "postal_code": "371602380",
            "telephone_number": "571-982-6636"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIVIA MEDICAL GROUP TENNESSEE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-11-24",
        "last_updated": "2022-07-13",
        "certification_date": "2022-07-13",
        "status": "A",
        "authorized_official_last_name": "ROLLER",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "ASSOCIATE DIRECTOR/ENROLLMENT",
        "authorized_official_telephone_number": "770-312-5226"
    },
    "taxonomies": [
        {
            "code": "207XX0005X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery, Sports Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sports Ortho Urgent Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Sports Ortho Urgent Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Robert Michael Powell
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• Hanna Marie Price, PHARMD
• Mary E Prince, RN
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• Olivia Christine Pullen, PT, DPT
• Elena Ruth Quinonez
• Tisha L Rader, B.S.
• Evelyn Ramirez

• Sports Medicine (Orthopaedic Surgery) Physician in Shelbyville, TN
• Providers in Shelbyville, TN by specialty
• Sports Medicine (Orthopaedic Surgery) Physician in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.