Provider Demographics
NPI:1437255395
Name:GRADY MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:GRADY MEMORIAL HOSPITAL CORPORATION
Other - Org Name:CRESTVIEW HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:CORA
Authorized Official - Middle Name:LEDARE
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-616-8110
Mailing Address - Street 1:2800 SPRINGDALE RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-7802
Mailing Address - Country:US
Mailing Address - Phone:404-616-8100
Mailing Address - Fax:
Practice Address - Street 1:2800 SPRINGDALE RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7802
Practice Address - Country:US
Practice Address - Phone:404-616-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-060-1275314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00273567AMedicaid
GA115525Medicare ID - Type Unspecified
GA0730700001Medicare NSC