Provider Demographics
NPI:1003986894
Name:CAPITAL REGION MEDICAL CENTER
Entity Type:Organization
Organization Name:CAPITAL REGION MEDICAL CENTER
Other - Org Name:CAPITAL REGION MEDICAL CENTER-HME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT-FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:LUEBBERING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-632-5100
Mailing Address - Street 1:7748 WATSON ROAD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-5407
Mailing Address - Country:US
Mailing Address - Phone:573-632-5750
Mailing Address - Fax:573-632-5868
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5750
Practice Address - Fax:573-632-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO412 12332B00000X
MO41212332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620158501Medicaid
MO620158501Medicaid