Healthcare Provider Details

I. General information

NPI: 1538117114
Provider Name (Legal Business Name): CAPITAL REGION MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 MADISON ST
JEFFERSON CITY MO
65101-3458
US

IV. Provider business mailing address

PO BOX 1128
JEFFERSON CITY MO
65102-1128
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-5510
  • Fax: 573-632-5810
Mailing address:
  • Phone: 573-632-5510
  • Fax: 573-632-5810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TOM LUEBBERING
Title or Position: VP OF FINANCE
Credential:
Phone: 573-632-5100