Provider Demographics
NPI:1649244690
Name:CAPITAL REGION MEDICAL CENTER
Entity Type:Organization
Organization Name:CAPITAL REGION MEDICAL CENTER
Other - Org Name:CAPITAL REGION PHYSICIANS - EDGEWOOD URGENT CARE
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 1:3308 W EDGEWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6891
Mailing Address - Country:US
Mailing Address - Phone:573-893-7848
Mailing Address - Fax:573-893-1984
Practice Address - Street 1:3308 W EDGEWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6891
Practice Address - Country:US
Practice Address - Phone:573-893-7848
Practice Address - Fax:573-893-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507613909Medicaid
MOPA2614OtherRR MEDICARE
MO507613909Medicaid