Provider Demographics
NPI:1447405568
Name:CAPITAL REGION MEDICAL CENTER
Entity Type:Organization
Organization Name:CAPITAL REGION MEDICAL CENTER
Other - Org Name:CAPITAL REGION PHYSICIANS - THE SLOAN CLINIC
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:R
Authorized Official - Last Name:LUEBBERING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-632-5100
Mailing Address - Street 1:3306 EMERALD LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6877
Mailing Address - Country:US
Mailing Address - Phone:573-632-5544
Mailing Address - Fax:573-635-0815
Practice Address - Street 1:1505 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2431
Practice Address - Country:US
Practice Address - Phone:573-632-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108684207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO249990557Medicaid