Provider Demographics
NPI:1073032660
Name:GRADY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:GRADY MEMORIAL HOSPITAL
Other - Org Name:FOMG WOUND CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SPELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-779-2150
Mailing Address - Street 1:2100 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2736
Mailing Address - Country:US
Mailing Address - Phone:405-224-2100
Mailing Address - Fax:405-779-2310
Practice Address - Street 1:2815 W ELK AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1517
Practice Address - Country:US
Practice Address - Phone:580-252-3400
Practice Address - Fax:405-779-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-14
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK239213E00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty