Provider Demographics
NPI:1285606392
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 1:103 BUSINESS HWY 54 NORTH
Mailing Address - Street 2:
Mailing Address - City:ELDON
Mailing Address - State:MO
Mailing Address - Zip Code:65026
Mailing Address - Country:US
Mailing Address - Phone:573-392-2124
Mailing Address - Fax:573-392-6375
Practice Address - Street 1:103 BUSINESS HWY 54 NORTH
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026
Practice Address - Country:US
Practice Address - Phone:573-392-2124
Practice Address - Fax:573-392-6375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508069101Medicaid
MO508069101Medicaid