Provider Demographics
NPI:1346242567
Name:PRIVIA MEDICAL GROUP WEST TEXAS, PLLC
Entity Type:Organization
Organization Name:PRIVIA MEDICAL GROUP WEST TEXAS, PLLC
Other - Org Name:ABILENE DIAGNOSTIC CLINIC, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-437-8645
Mailing Address - Street 1:PO BOX 5409
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79608-5409
Mailing Address - Country:US
Mailing Address - Phone:325-437-8655
Mailing Address - Fax:325-437-8647
Practice Address - Street 1:1665 ANTILLEY RD
Practice Address - Street 2:# 200
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5265
Practice Address - Country:US
Practice Address - Phone:325-793-5375
Practice Address - Fax:325-793-5384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1306102-02Medicaid
TX00J917Medicare PIN