Provider Demographics
NPI:1083912265
Name:CAPITAL REGION MEDICAL CENTER
Entity Type:Organization
Organization Name:CAPITAL REGION MEDICAL CENTER
Other - Org Name:CAPITAL REGION PHYSICIANS - MADISON STREET OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
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 1:1014 MADISON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-3458
Mailing Address - Country:US
Mailing Address - Phone:573-634-3496
Mailing Address - Fax:573-635-5260
Practice Address - Street 1:1014 MADISON ST
Practice Address - Street 2:SUITE B
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-3458
Practice Address - Country:US
Practice Address - Phone:573-634-3496
Practice Address - Fax:573-635-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO419-15207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty