Provider Demographics
NPI:1093474769
Name:PRIVIA MEDICAL GROUP TENNESSEE LLC
Entity type:Organization
Organization Name:PRIVIA MEDICAL GROUP TENNESSEE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-312-5226
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:571-982-6636
Mailing Address - Fax:
Practice Address - Street 1:2113 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-5106
Practice Address - Country:US
Practice Address - Phone:571-982-6636
Practice Address - Fax:240-696-1353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-10
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty