Healthcare Provider Details

I. General information

NPI: 1114243813
Provider Name (Legal Business Name): GRADY MEMORIAL HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE BOX 26019
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

PO BOX 935102
ATLANTA GA
31193-5102
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-8880
  • Fax: 404-616-9076
Mailing address:
  • Phone: 404-616-5887
  • Fax: 404-616-9076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY JEFFERSON
Title or Position: EXEC VP, GENERAL COUNSEL
Credential: ESQ
Phone: 404-616-6180