Healthcare Provider Details

I. General information

NPI: 1669134813
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP GULF COAST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NUCARE FOOT & ANKLE SPECIALISTS, 12238 QUEENSTON BLVD STE K
HOUSTON TX
77095-5351
US

IV. Provider business mailing address

1200 BINZ ST STE 1490
HOUSTON TX
77004-6946
US

V. Phone/Fax

Practice location:
  • Phone: 281-982-0868
  • Fax: 281-982-0866
Mailing address:
  • Phone: 713-512-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

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