Provider Demographics
NPI:1306867213
Name:CAPITOL UROLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CAPITOL UROLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-983-5557
Mailing Address - Street 1:1561 CREEKSIDE DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3492
Mailing Address - Country:US
Mailing Address - Phone:916-983-5557
Mailing Address - Fax:916-983-7878
Practice Address - Street 1:1561 CREEKSIDE DR
Practice Address - Street 2:SUITE 170
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-983-5557
Practice Address - Fax:916-983-7878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208800000X
CAG59349261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065840Medicaid
CAGR0065840Medicaid
E89771Medicare UPIN