Provider Demographics
NPI:1457167033
Name:PRIVIA MEDICAL GROUP GULF COAST PLLC
Entity type:Organization
Organization Name:PRIVIA MEDICAL GROUP GULF COAST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AVP
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-512-7613
Mailing Address - Street 1:1200 BINZ ST STE 1490
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-6946
Mailing Address - Country:US
Mailing Address - Phone:210-874-5260
Mailing Address - Fax:
Practice Address - Street 1:5939 BABCOCK RD STE 112
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3462
Practice Address - Country:US
Practice Address - Phone:210-874-5260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIVIA MEDICAL GROUP GULF COAST PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty