Basic Information
| Provider Information | |||||||||
| NPI: | 1306867213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPITOL UROLOGY MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1561 CREEKSIDE DR | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835557 | ||||||||
| FaxNumber: | 9169837878 | ||||||||
| Practice Location | |||||||||
| Address1: | 1561 CREEKSIDE DR | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835557 | ||||||||
| FaxNumber: | 9169837878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 11/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | JOYCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9169835557 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | G59349 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | GR0065840 | 05 | CA | MEDICAID |