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DSH110079N GRADY MEMORIAL HOSPITAL (Active)
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Main Details
Name
GRADY MEMORIAL HOSPITAL
Subdivision Name
Brookhaven Health Center
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110079N
Medicare Provider Number
110079
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
5/4/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/21/2012
Last Recertification Date
9/3/2024
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
2695 Buford Hwy NE
Suite 200
Atlanta, GA 30324-3278
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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