Provider Demographics
NPI:1700043791
Name:CAPITAL REGION MEDICAL CENTER
Entity Type:Organization
Organization Name:CAPITAL REGION MEDICAL CENTER
Other - Org Name:CAPITAL REGION PHYSICIANS - RADIOLOGY
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:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1128
Mailing Address - Country:US
Mailing Address - Phone:573-632-5000
Mailing Address - Fax:573-632-5876
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65102-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5000
Practice Address - Fax:573-632-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507398006Medicaid
MO507398006Medicaid