Provider Demographics
NPI:1598352270
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:AUTHORIZED OFFICIAL
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:571-982-6636
Mailing Address - Fax:240-696-1353
Practice Address - Street 1:210 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4512
Practice Address - Country:US
Practice Address - Phone:281-593-1500
Practice Address - Fax:281-593-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty