Basic Information
| Provider Information | |||||||||
| NPI: | 1366547101 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPITOL ER GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12350 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926852350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006577104 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 GATEWAY CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292039802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038654500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | WINN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE OFFICER MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8006577103 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP4107 | 05 | SC | MEDICAID | GP4106 | 05 | SC | MEDICAID |