Basic Information
| Provider Information | |||||||||
| NPI: | 1578592788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRADY MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | RUSH SPRINGS FAMILY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2220 W IOWA AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242300 | ||||||||
| FaxNumber: | 4057792143 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 SOUTH RUSH AVE | ||||||||
| Address2: | |||||||||
| City: | RUSH SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730820277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804762527 | ||||||||
| FaxNumber: | 5804763707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
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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 | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100700820G | 05 | OK | MEDICAID |