Provider Demographics
NPI:1164859260
Name:GRADY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:GRADY MEMORIAL HOSPITAL
Other - Org Name:FIVE OAKS FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:KEAN
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:SUITE A
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:405-779-2346
Practice Address - Street 1:2100 W IOWA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2736
Practice Address - Country:US
Practice Address - Phone:405-224-2100
Practice Address - Fax:405-779-2346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207Q00000X, 207V00000X, 261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700820 KMedicaid
OK409956Medicare PIN
OK373478Medicare Oscar/Certification