Provider Demographics
NPI:1053385096
Name:CAPITAL REGION MEDICAL CENTER
Entity type:Organization
Organization Name:CAPITAL REGION MEDICAL CENTER
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: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:573-632-5576
Mailing Address - Fax:573-632-5860
Practice Address - Street 1:1432 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-632-5576
Practice Address - Fax:573-632-5860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506023209Medicaid
MOCU0751OtherRR MEDICARE
MO000013650Medicare ID - Type Unspecified