Provider Demographics
NPI:1063489151
Name:KHOURI, GRACE NIMAT (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:NIMAT
Last Name:KHOURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NIMAT
Other - Middle Name:RACHID
Other - Last Name:KHURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8674 1230 E. MAIN STREET
Mailing Address - Street 2:MANKATO CLINIC LTD
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:952-483-4301
Practice Address - Street 1:1230 E. MAIN STREET
Practice Address - Street 2:MANKATO CLINIC, LTD
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:952-843-4301
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30851207Y00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN836385400Medicaid
930001482Medicare ID - Type Unspecified
MN836385400Medicaid