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DSH110079AT GRADY MEMORIAL HOSPITAL (Active)
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Main Details
Name
GRADY MEMORIAL HOSPITAL
Subdivision Name
CORRELL PAVILION - Radiology IR
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110079AT
Medicare Provider Number
110079
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
7/12/2024
Participating Start Date
10/1/2024
Participating Approval Date
7/17/2024
Last Recertification Date
Contacts
Authorizing Official
Grady Health System
John Haupert, Chief Executive Officer
(404) 616-4254
Primary Contact
Grady Health System
Kelcy Susannah Freeman, Pharmacy Program Coordinator
(404) 616-5909
Addresses
Street Address
80 GILMER ST SE
ATLANTA, GA 30303
Billing Address
Grady Health System Accounts Payable
50 Hurt Plaza SE
Suite 1300
Atlanta, GA 30303-2946
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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