Healthcare Provider Details

I. General information

NPI: 1750715439
Provider Name (Legal Business Name): GRADY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 E HIGHWAY 37
TUTTLE OK
73089-8791
US

IV. Provider business mailing address

2220 W IOWA AVE
CHICKASHA OK
73018-2738
US

V. Phone/Fax

Practice location:
  • Phone: 405-381-2301
  • Fax: 405-381-3592
Mailing address:
  • Phone: 405-779-2180
  • Fax: 405-779-2599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100700820P
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: MR. WARREN KEAN SPELLMAN
Title or Position: CEO
Credential:
Phone: 405-779-2150