=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114048154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFTON MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 06/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 59 GRASSO PLZ
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63123-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-638-9309
-----------------------------------------------------
Fax | 314-638-9333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 59 GRASSO PLZ
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63123-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-638-9309
-----------------------------------------------------
Fax | 314-638-9333
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. RUBILINDA GIMENA CASINO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 314-638-9309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | R5P40
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------