Provider Demographics
NPI:1194833400
Name:SOUTHERN HEALTH CORP. OF HOUSTON, INC.
Entity Type:Organization
Organization Name:SOUTHERN HEALTH CORP. OF HOUSTON, INC.
Other - Org Name:TRACE FAMILY HEALTH & INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-456-3700
Mailing Address - Street 1:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-0432
Mailing Address - Country:US
Mailing Address - Phone:662-456-2800
Mailing Address - Fax:662-456-1715
Practice Address - Street 1:1002 E MADISON ST STE B
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2428
Practice Address - Country:US
Practice Address - Phone:662-456-2800
Practice Address - Fax:662-456-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS258518OtherTRISPAN
MSC02335OtherMEDICARE PART B GROUP
MS07978511Medicaid
MSC02335OtherMEDICARE PART B GROUP
MS258518Medicare Oscar/Certification