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DSH110079V GRADY MEMORIAL HOSPITAL (Active)
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Main Details
Name
GRADY MEMORIAL HOSPITAL
Subdivision Name
Correll Pavilion - Surgery Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110079V
Medicare Provider Number
110079
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
10/4/2022
Participating Start Date
1/1/2023
Participating Approval Date
10/11/2022
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
80 Gilmer Street 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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