Provider Demographics
NPI:1649514050
Name:CAPITAL REGION RESIDENT CLINIC
Entity type:Organization
Organization Name:CAPITAL REGION RESIDENT CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1111 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2753
Mailing Address - Country:US
Mailing Address - Phone:573-632-5027
Mailing Address - Fax:573-634-5878
Practice Address - Street 1:220 MADISON ST.
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65102
Practice Address - Country:US
Practice Address - Phone:573-632-4900
Practice Address - Fax:573-644-6650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty