MEDICARE: PRIVIA MEDICAL GROUP GULF COAST PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician
2	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1639985211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIVIA MEDICAL GROUP GULF COAST PLLC

Provider Business Mailing Address
First Line	:	1200 BINZ ST STE 1490
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-6946
Country	:	US
Telephone Number	:	713-512-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	21038 US HIGHWAY 281 N STE 100
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-7556
Country	:	US
Telephone Number	:	210-874-5260
Fax Number	:

Authorized Official
Title or Position	:	AVP
Name	:	BARBARA JORDAN
Credential	:	AVP
Telephone Number	:	281-816-7860

Provider Enumeration Date	:	12/09/2024
Last Update Date	:	12/09/2024

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