MEDICARE: CAPITAL REGION MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner
2	207V00000X	Obstetrics & Gynecology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CI5354	OTHER	MO	RR MEDICARE
3	DA4608	OTHER	MO	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538117114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITAL REGION MEDICAL CENTER

Provider Business Mailing Address
First Line	:	PO BOX 1128
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65102-1128
Country	:	US
Telephone Number	:	573-632-5510
Fax Number	:	573-632-5810

Provider Business Practice Location Address
First Line	:	1014 MADISON ST
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65101-3458
Country	:	US
Telephone Number	:	573-632-5510
Fax Number	:	573-632-5810

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	TOM LUEBBERING
Credential	:
Telephone Number	:	573-632-5100

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	08/21/2014

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Directions to “CAPITAL REGION MEDICAL CENTER ” Practice Location

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