Provider Demographics
NPI:1023572690
Name:SPECIALIST IN AGING SUCCESSFULLY LLC
Entity Type:Organization
Organization Name:SPECIALIST IN AGING SUCCESSFULLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASIF
Authorized Official - Middle Name:
Authorized Official - Last Name:BHUTTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-209-5100
Mailing Address - Street 1:PO BOX 8356
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-0356
Mailing Address - Country:US
Mailing Address - Phone:314-209-5100
Mailing Address - Fax:
Practice Address - Street 1:3466 BRIDGELAND DR STE 105
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2606
Practice Address - Country:US
Practice Address - Phone:314-209-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty