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DSH110079L GRADY MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
GRADY MEMORIAL HOSPITAL
Subdivision Name
Behavioral Health Outpatient Center
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110079L
Medicare Provider Number
110079
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
5/4/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/21/2012
Last Recertification Date
9/8/2023
Termination Date
Termination Reason
10/1/2024
Other
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
10 Park Place NE
Atlanta, GA 30303
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
June 2025
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