Provider Demographics
NPI:1972130003
Name:PRIVIA MEDICAL GROUP GULF COAST, PLLC
Entity Type:Organization
Organization Name:PRIVIA MEDICAL GROUP GULF COAST, PLLC
Other - Org Name:UNIVERSITY PAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DELEGATED 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:713-512-7252
Mailing Address - Fax:
Practice Address - Street 1:9305 PINECROFT DR STE 104
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3482
Practice Address - Country:US
Practice Address - Phone:281-896-0013
Practice Address - Fax:281-896-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-26
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7803750001OtherMEDICARE DME