Healthcare Provider Details

I. General information

NPI: 1518680123
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP GULF COAST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BEE CREEK RD UNIT 203
SPICEWOOD TX
78669-7018
US

IV. Provider business mailing address

1200 BINZ ST STE 1490
HOUSTON TX
77004-6946
US

V. Phone/Fax

Practice location:
  • Phone: 512-907-3100
  • Fax:
Mailing address:
  • Phone: 713-512-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: BARBARA JORDAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 713-512-7613