Healthcare Provider Details

I. General information

NPI: 1447405568
Provider Name (Legal Business Name): CAPITAL REGION MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 SOUTHWEST BLVD
JEFFERSON CITY MO
65109-2431
US

IV. Provider business mailing address

3306 EMERALD LN SUITE A
JEFFERSON CITY MO
65109-6877
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-5544
  • Fax:
Mailing address:
  • Phone: 573-632-5544
  • Fax: 573-635-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number108684
License Number StateMO

VIII. Authorized Official

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