Provider Demographics
NPI:1790725927
Name:CAPITAL MEDICAL GROUP TRUST
Entity Type:Organization
Organization Name:CAPITAL MEDICAL GROUP TRUST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-454-5171
Mailing Address - Street 1:1301 WEST 38TH STREET
Mailing Address - Street 2:SUITE 601
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 W 38TH ST
Practice Address - Street 2:SUITE 601
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1000
Practice Address - Country:US
Practice Address - Phone:512-454-5171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC14396Medicare UPIN
TXG67925Medicare UPIN
TXF88218Medicare UPIN
TXCO9079Medicare PIN
TX00H93EMedicare PIN