Basic Information
| Provider Information | |||||||||
| NPI: | 1659302115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRADY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 W IOWA AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242100 | ||||||||
| FaxNumber: | 4057792346 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 W IOWA AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242100 | ||||||||
| FaxNumber: | 4057792346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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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 | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 100700820E | 05 | OK | MEDICAID |