Provider Demographics
NPI:1356341184
Name:PRIVIA MEDICAL GROUP WEST TEXAS, PLLC
Entity type:Organization
Organization Name:PRIVIA MEDICAL GROUP WEST TEXAS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:SUITE 200
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5265
Practice Address - Country:US
Practice Address - Phone:325-437-8655
Practice Address - Fax:325-437-8647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR22802471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0174DCMedicare ID - Type UnspecifiedIMAGING SERVICES