Basic Information
| Provider Information | |||||||||
| NPI: | 1386364412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIVIA MEDICAL GROUP GULF COAST PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 BINZ ST STE 1490 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770046946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135127700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4303 VICTORY DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787047507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124623627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2022 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | AVP RCM MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 7135127613 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIVIA MEDICAL GROUP GULF COAST, PLLC | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.