Provider Demographics
NPI:1366465502
Name:SOUTHERN HEALTH CORP OF HOUSTON, INC.
Entity Type:Organization
Organization Name:SOUTHERN HEALTH CORP OF HOUSTON, INC.
Other - Org Name:TRACE REGIONAL HOSPITAL
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 626
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851
Mailing Address - Country:US
Mailing Address - Phone:662-456-3701
Mailing Address - Fax:662-456-1083
Practice Address - Street 1:1002 E MADISON ST
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:662-456-3700
Practice Address - Fax:662-456-1083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12296282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC 02044OtherMEDICARE / CAHABA
MSC02335OtherMEDICARE / CAHABA
MS00220415Medicaid
MS09013117Medicaid
MS09013354Medicaid
MSC00717OtherMEDICARE / CAHABA
000020031OtherBC
MS00220424Medicaid
MS09013117Medicaid
MS00220424Medicaid
MS09013354Medicaid