Provider Demographics
NPI:1528251337
Name:AFFTON MEDICAL CLINIC
Entity type:Organization
Organization Name:AFFTON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUBILINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-638-9309
Mailing Address - Street 1:PO BOX 4341
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-0141
Mailing Address - Country:US
Mailing Address - Phone:314-638-9309
Mailing Address - Fax:314-638-9333
Practice Address - Street 1:84 GRASSO PLAZA
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123
Practice Address - Country:US
Practice Address - Phone:314-638-9309
Practice Address - Fax:314-637-9333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO50291440Medicaid