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DSH110079AG GRADY MEMORIAL HOSPITAL (Active)
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Main Details
Name
GRADY MEMORIAL HOSPITAL
Subdivision Name
Hughes Spalding Childrens Hospital - Sickle Cell Clinic
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH110079AG
Medicare Provider Number
110079
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
7/11/2023
Participating Start Date
10/1/2023
Participating Approval Date
7/25/2023
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
35 Jesse Hill Jr Drive SE
Atlanta, GA 30303-3032
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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