Healthcare Provider Details

I. General information

NPI: 1134901960
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP GULF COAST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 UNIVERSITY DR E STE 245
BRYAN TX
77802-3483
US

IV. Provider business mailing address

1200 BINZ ST STE 1490
HOUSTON TX
77004-6946
US

V. Phone/Fax

Practice location:
  • Phone: 979-731-3100
  • Fax:
Mailing address:
  • Phone: 713-512-7700
  • Fax: 832-767-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

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