Healthcare Provider Details

I. General information

NPI: 1689267783
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP GULF COAST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11614 FM 2244 RD STE 150
AUSTIN TX
78738-5471
US

IV. Provider business mailing address

1200 BINZ ST STE 1490
HOUSTON TX
77004-6946
US

V. Phone/Fax

Practice location:
  • Phone: 512-399-5711
  • Fax: 512-339-5707
Mailing address:
  • Phone: 713-512-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: BARBARA JORDAN
Title or Position: ASSOCIATE VP, REVENUE CYCLE
Credential:
Phone: 713-512-7613