Healthcare Provider Details

I. General information

NPI: 1114048154
Provider Name (Legal Business Name): AFFTON MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 GRASSO PLZ
SAINT LOUIS MO
63123-3107
US

IV. Provider business mailing address

59 GRASSO PLZ
SAINT LOUIS MO
63123-3107
US

V. Phone/Fax

Practice location:
  • Phone: 314-638-9309
  • Fax: 314-638-9333
Mailing address:
  • Phone: 314-638-9309
  • Fax: 314-638-9333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberR5P40
License Number StateMO

VIII. Authorized Official

Name: DR. RUBILINDA GIMENA CASINO
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 314-638-9309