Basic Information
| Provider Information | |||||||||
| NPI: | 1437698784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRADY MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | ANADARKO CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2220 W IOWA AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057792721 | ||||||||
| FaxNumber: | 4057792310 | ||||||||
| Practice Location | |||||||||
| Address1: | 1104 E CENTRAL BLVD | ||||||||
| Address2: | |||||||||
| City: | ANADARKO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730054406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052476685 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2017 | ||||||||
| LastUpdateDate: | 02/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | SPELLMAN | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | KEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4057792150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | OK | MEDICAID |