Provider Demographics
NPI:1609071976
Name:SOUTHLAKE SPECIALTY HOSPITAL, LLC
Entity Type:Organization
Organization Name:SOUTHLAKE SPECIALTY HOSPITAL, LLC
Other - Org Name:TEXAS HEALTH HARRIS METHODIST HOSPITAL SOUTHLAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-748-8784
Mailing Address - Street 1:PO BOX 676252
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-6252
Mailing Address - Country:US
Mailing Address - Phone:817-748-8700
Mailing Address - Fax:972-419-8118
Practice Address - Street 1:1545 SOUTHLAKE BLVD.
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6422
Practice Address - Country:US
Practice Address - Phone:817-748-8784
Practice Address - Fax:817-748-8787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008128282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171461002Medicaid
TXHH1061OtherBLUE CROSS PROVIDER ID
TX171461002Medicaid
450888Medicare Oscar/Certification