Basic Information
| Provider Information | |||||||||
| NPI: | 1518680123 | ||||||||
| 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 | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770046946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135127700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4900 BEE CREEK RD UNIT 203 | ||||||||
| Address2: | |||||||||
| City: | SPICEWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786697018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129073100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2022 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7135127613 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
No ID Information.