Provider Demographics
NPI:1942484365
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:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:STATEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-456-1000
Mailing Address - Street 1:P.O. BX 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:662-456-3700
Mailing Address - Fax:662-456-1159
Practice Address - Street 1:1002 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2417
Practice Address - Country:US
Practice Address - Phone:662-456-3700
Practice Address - Fax:662-456-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013354Medicaid
MS09013117Medicaid
MSC00717Medicare UPIN