Provider Demographics
NPI:1659014827
Name:KOLLANNOOR SAMUEL, GRACE (MBBS, MS, PHD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:KOLLANNOOR SAMUEL
Suffix:
Gender:F
Credentials:MBBS, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8450 SEASONS PKWY
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4402
Practice Address - Country:US
Practice Address - Phone:651-702-5300
Practice Address - Fax:651-702-5305
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN78971207R00000X, 207R00000X
WI8472620208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice