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DSH110079F GRADY MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
GRADY MEMORIAL HOSPITAL
Subdivision Name
NORTH DEKALB HEALTH CENTER
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110079F
Medicare Provider Number
110079
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
9/5/2007
Participating Start Date
10/1/2002
Participating Approval Date
9/5/2007
Last Recertification Date
8/23/2016
Termination Date
Termination Reason
1/1/2018
Site closure
Contacts
Authorizing Official
Grady Health System
John Haupert, Chief Executive Officer
(404) 616-4254
Primary Contact
Grady Health System
Val Dixon Hallman, Director Pharmacy Administration
(404) 616-3576
Addresses
Street Address
3807 CLAIRMONT RD, SE
CHAMBLEE, GA 30341
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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