Privia Medical Group, LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

Legal business name

PRIVIA MEDICAL GROUP, LLC

Practice address

8988 Lorton Station Blvd Ste 100
Lorton, VA 22079-4757

Phone

(571) 366-8850

NPI assigned

Sep 26, 2019

Organization subpart

No

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

Authorized official

Name

Courtney Ainsworth Ivess

Title

Associate Director, Credentialing

Phone

(571) 366-8831

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Mount Vernon Internal Medicine Doing business as

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

{
    "created_epoch": "1569456000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583366400000",
    "number": "1962053306",
    "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": "571-366-8850"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8988 LORTON STATION BLVD STE 100",
            "city": "LORTON",
            "state": "VA",
            "postal_code": "220794757",
            "telephone_number": "571-366-8850"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIVIA MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-09-26",
        "last_updated": "2020-03-05",
        "certification_date": "2020-03-05",
        "status": "A",
        "authorized_official_last_name": "IVESS",
        "authorized_official_first_name": "COURTNEY",
        "authorized_official_middle_name": "AINSWORTH",
        "authorized_official_title_or_position": "ASSOCIATE DIRECTOR, CREDENTIALING",
        "authorized_official_telephone_number": "571-366-8831"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "213E00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Podiatrist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DME",
            "identifier": "7442750009",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mount Vernon Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Mount Vernon Internal Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• All providers in Lorton, VA
• Internal Medicine Physician in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 5, 2020; 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.