Basic Information
| Provider Information | |||||||||
| NPI: | 1023572690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALIST IN AGING SUCCESSFULLY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8356 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631320356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142095100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3466 BRIDGELAND DR STE 105 | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142095100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2019 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | BHUTTO | ||||||||
| AuthorizedOfficialFirstName: | ASIF | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3142095100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.