Provider Demographics
NPI:1578592788
Name:GRADY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:GRADY MEMORIAL HOSPITAL
Other - Org Name:RUSH SPRINGS 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 1:2220 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2738
Mailing Address - Country:US
Mailing Address - Phone:405-224-2300
Mailing Address - Fax:405-779-2143
Practice Address - Street 1:113 SOUTH RUSH AVE
Practice Address - Street 2:
Practice Address - City:RUSH SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:73082-0277
Practice Address - Country:US
Practice Address - Phone:580-476-2527
Practice Address - Fax:580-476-3707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700820GMedicaid
OK373449Medicare Oscar/Certification
OK100700820GMedicaid