Provider Demographics
NPI:1447238092
Name:CAPITOL CITY MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:CAPITOL CITY MEDICAL GROUP, INC
Other - Org Name:CAPITAL CITY MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:ULLERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-920-1200
Mailing Address - Street 1:500 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6523
Mailing Address - Country:US
Mailing Address - Phone:916-920-1200
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6523
Practice Address - Country:US
Practice Address - Phone:916-920-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2471B0102XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistBone DensitometryGroup - Single Specialty
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0088950Medicaid
CAZZZ61216ZOtherBLUE SHIELD PROVIDER ID
CAZZZ61216ZOtherBLUE SHIELD PROVIDER ID
CAGR0088950Medicaid
CA=========OtherBLUE CROSS PROVIDER ID