Healthcare Provider Details

I. General information

NPI: 1023572690
Provider Name (Legal Business Name): SPECIALIST IN AGING SUCCESSFULLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 BRIDGELAND DR STE 105
BRIDGETON MO
63044-2606
US

IV. Provider business mailing address

PO BOX 8356
SAINT LOUIS MO
63132-0356
US

V. Phone/Fax

Practice location:
  • Phone: 314-209-5100
  • Fax:
Mailing address:
  • Phone: 314-209-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ASIF BHUTTO
Title or Position: MEMBER
Credential: MD
Phone: 314-209-5100