Healthcare Provider Details

I. General information

NPI: 1487631776
Provider Name (Legal Business Name): CAPITAL REGION MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 KIDWELL DR
VERSAILLES MO
65084-1784
US

IV. Provider business mailing address

901 KIDWELL DR
VERSAILLES MO
65084-1784
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-4666
  • Fax: 573-378-5099
Mailing address:
  • Phone: 573-378-4666
  • Fax: 573-378-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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