Healthcare Provider Details

I. General information

NPI: 1174008452
Provider Name (Legal Business Name): RITA KHOURY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 S GRAND BLVD
SAINT LOUIS MO
63104-1027
US

IV. Provider business mailing address

4362 LINDELL BLVD APT 1N
SAINT LOUIS MO
63108-2744
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4828
  • Fax:
Mailing address:
  • Phone: 314-757-4394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number2018023525
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: