Healthcare Provider Details

I. General information

NPI: 1639985211
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP GULF COAST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21038 US HIGHWAY 281 N STE 100
SAN ANTONIO TX
78258-7556
US

IV. Provider business mailing address

1200 BINZ ST STE 1490
HOUSTON TX
77004-6946
US

V. Phone/Fax

Practice location:
  • Phone: 210-874-5260
  • Fax:
Mailing address:
  • Phone: 713-512-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BARBARA JORDAN
Title or Position: AVP
Credential: AVP
Phone: 281-816-7860