Basic Information
Provider Information | |||||||||
NPI: | 1598352270 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIVIA MEDICAL GROUP GULF COAST, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 BINZ ST STE 1490 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770046946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5719826636 | ||||||||
FaxNumber: | 2406961353 | ||||||||
Practice Location | |||||||||
Address1: | 210 E HOUSTON ST | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | TX | ||||||||
PostalCode: | 773274512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2815931500 | ||||||||
FaxNumber: | 2815931509 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2020 | ||||||||
LastUpdateDate: | 12/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JORDAN | ||||||||
AuthorizedOfficialFirstName: | BARBARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 7135127613 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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NPICertificationDate: | 12/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.