Provider Demographics
NPI:1114048154
Name:AFFTON MEDICAL CLINIC
Entity Type:Organization
Organization Name:AFFTON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUBILINDA
Authorized Official - Middle Name:GIMENA
Authorized Official - Last Name:CASINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-638-9309
Mailing Address - Street 1:59 GRASSO PLZ
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-3107
Mailing Address - Country:US
Mailing Address - Phone:314-638-9309
Mailing Address - Fax:314-638-9333
Practice Address - Street 1:59 GRASSO PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-3107
Practice Address - Country:US
Practice Address - Phone:314-638-9309
Practice Address - Fax:314-638-9333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5P402080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205357908Medicaid
MOH85070Medicare UPIN