Provider Demographics
NPI:1790181550
Name:CAPITAL REGIONAL MEDICAL GROUP
Entity Type:Organization
Organization Name:CAPITAL REGIONAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-878-8235
Mailing Address - Street 1:363 MILESTONE DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-3575
Mailing Address - Country:US
Mailing Address - Phone:954-445-7760
Mailing Address - Fax:
Practice Address - Street 1:2770 CAPITAL MEDICAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8417
Practice Address - Country:US
Practice Address - Phone:850-878-8235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAPITAL REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9188795305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization