Healthcare Provider Details

I. General information

NPI: 1578969465
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP GULF COAST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 03/17/2024
Certification Date: 03/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 FANNIN ST STE 4000
HOUSTON TX
77054-2935
US

IV. Provider business mailing address

1200 BINZ ST STE 1490
HOUSTON TX
77004-6946
US

V. Phone/Fax

Practice location:
  • Phone: 713-512-7500
  • Fax:
Mailing address:
  • Phone: 713-512-7613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

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