Provider Demographics
NPI:1750715439
Name:GRADY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:GRADY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
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:405-779-2180
Mailing Address - Fax:405-779-2599
Practice Address - Street 1:4805 E HIGHWAY 37
Practice Address - Street 2:
Practice Address - City:TUTTLE
Practice Address - State:OK
Practice Address - Zip Code:73089-8791
Practice Address - Country:US
Practice Address - Phone:405-381-2301
Practice Address - Fax:405-381-3592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700820PMedicaid