NPIMap

Organization Active NPI

Southlake Specialty Hospital, LLC

  • General Acute Care Hospital
  • Southlake, TX
National Provider Identifier
1629064928
Registry record updated Feb 18, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
License
008128 Issued in TX
Legal business name
SOUTHLAKE SPECIALTY HOSPITAL, LLC
Practice address
1545 Southlake Blvd.
Southlake, TX 76092-6422
Phone
(817) 748-8784
Fax
(817) 748-8787
NPI assigned
Sep 22, 2005
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Mrs. Traci Bernard
Title
President
Phone
(817) 748-8784

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Facilities with the same owner 32

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 32

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 177

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 177

Care Compare: Hospital

Medicare Care Compare
Listed as
Texas Health Harris Methodist Hospital SouthlakeCCN 450888
Type
Acute Care Hospitals
Ownership
Proprietary
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D1029714Texas Health Harris Methodist Hospital Southlake1545 E Southlake Blvd, Southlake, TX 76092AccreditationOct 4, 2026

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040903000689 TX Part a Provider - Hospital 2264408996 1 other NPI on this enrollment
Practice locations: Bedford, TX; Fort Worth, TX; Southlake, TX

Hospital certification: CCN 450888

Medicare enrollment files
Legal name
SOUTHLAKE SPECIALTY HOSPITAL LLC
Doing business as
TEXAS HEALTH HARRIS METHODIST HOSPITAL SOUTHLAKE
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Nov 19, 2004
Last certification
Mar 20, 2025
Beds
17
Ownership / control type
Private (for profit)
Organization structure
LLCProprietary
Incorporated
Nov 9, 2007 in TX
Enrollment address
1545 E Southlake Blvd
Southlake, TX 76092-6422
Main/Primary Hospital Location
Hospital subgroups
General, Acute care, Specialty hospital

All disclosed owners & managing parties 10

Medicare enrollment files

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Phuong Luu Individual Contracted Managing EmployeeAccounting Manager Jun 19, 2006
Corporate OfficerAccounting Manager Jun 19, 2006
Jeffrey Wayne Mincher Individual Corporate OfficerSVP Chief Revenue Officer Jan 1, 2023
Texas Health Resources Organization, Arlington, TX Corporation, Non-profit 5% Or Greater Direct Ownership Interest Sep 1, 2011 54%
Operational/Managerial Control Jan 1, 2023
Fraser Hay Individual Corporate DirectorBoard Member Oct 28, 2025
John D Mitchell Individual Corporate DirectorBoard Member Oct 28, 2025
Mitchell J Mulvehill Individual Corporate OfficerInterim President Oct 1, 2025
David Rothbart MD PA Organization, Dallas, TX Medical provider/supplier 5% Or Greater Direct Ownership Interest Nov 1, 2014 8.77%
John E Whitely Individual Corporate OfficerTHR Corporate Offficer Jan 1, 2023
Corporate DirectorBoard Member Oct 28, 2025
Monika Mathur Individual Corporate DirectorBoard Member Oct 28, 2025
Bryan Bunderson Individual Corporate OfficerInterim Chief Nursing Officer Mar 8, 2026
W-2 Managing EmployeeInterim Chief Nursing Officer Mar 8, 2026

National Provider Directory

National Provider Directory

Locations

2419 Highway 121
Bedford, TX 76021
Phone (817) 835-8025

12650 N Beach St
Ste 150
Fort Worth, TX 76244
Phone (817) 402-0218

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X 008128 TX Primary

Addresses

NPPES NPI Registry

Primary practice location

1545 Southlake Blvd.
Southlake, TX 76092-6422

Mailing address

PO Box 735801
Dallas, TX 75373-5801
Phone (972) 419-6704

Other identifiers 2

NPPES NPI Registry
IdentifierTypeStateIssuer
1714610-01MedicaidTX
HH1061OtherTXBCBS PROVIDER NUMBER

Other names 1

NPPES NPI Registry
  • Texas Health Harris Methodist Hospital Southlake Doing business as

Electronic endpoints 2

NPPES NPI Registry
TypeEndpointUseAffiliation
FHIR URL https://epproxy.texashealth.org/FHIR/api/FHIR/DSTU2/ Other
Direct Messaging Address Gateway@Direct.TexasHealth.org Direct

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Feb 18, 2025.

{
    "created_epoch": "1127347200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1739836800000",
    "number": "1629064928",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 735801",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "753735801",
            "telephone_number": "972-419-6704",
            "fax_number": "972-419-8118"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1545 SOUTHLAKE BLVD.",
            "city": "SOUTHLAKE",
            "state": "TX",
            "postal_code": "760926422",
            "telephone_number": "817-748-8784",
            "fax_number": "817-748-8787"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHLAKE SPECIALTY HOSPITAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-22",
        "last_updated": "2025-02-18",
        "certification_date": "2025-02-18",
        "status": "A",
        "authorized_official_last_name": "BERNARD",
        "authorized_official_first_name": "TRACI",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "817-748-8784",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "TX",
            "license": "008128",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1714610-01",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PROVIDER NUMBER",
            "identifier": "HH1061",
            "state": "TX"
        }
    ],
    "endpoints": [
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://epproxy.texashealth.org/FHIR/api/FHIR/DSTU2/",
            "affiliation": "Y",
            "endpointDescription": "FHIR API Endpoint",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "Information Sharing",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Standards based healthcare information",
            "address_1": "612 E LaMar Blvd",
            "city": "Arlington",
            "state": "TX",
            "country_code": "US",
            "postal_code": "760114121",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "Gateway@Direct.TexasHealth.org",
            "affiliation": "Y",
            "endpointDescription": "Direct Address",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Standards based healthcare information",
            "address_1": "612 E LaMar Blvd",
            "city": "Arlington",
            "state": "TX",
            "country_code": "US",
            "postal_code": "760114121",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Texas Health Harris Methodist Hospital Southlake",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Texas Health Harris Methodist Hospital Southlake",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Southlake, TX

Sources for this page

Verify at the official NPI Registry.