Provider Number
0000-445912-00
Health Number Version Date of Birth Account Number Pay. Prog Payee
990 114 7000 RF Nov, 20, 1999
Referred By Master No In-Patient Admission
Service Fee Number of Service Date Diagnostic Service Fee Number of Service Date Diagnostic
Code Submitted Services YR MO DY Code Code Submitted Services YR MO DY Code
K013 $100-150 1 Dec, 01, 2024 035 K013 $100-150 1 Nov, 20, 1999 035
Provider Number
0000-445912-00
Health Number Version Date of Birth Accounting Number Pay. Prog Payee
8456527455 PG Jan, 06, 1955
Referred By Facility No In-Patient Admission
Service Fee Number of Service Date Diagnostic Service Fee Number of Service Date Diagnostic
Code Submitted Services YR MO DY Code Code Submitted Services YR MO DY Code
2 Nov 15th Nov 15th
A003A $87.35 2 Nov 15th A003A $87.35 Nov 15th
CPT99211 $75 Nov 15th 401 CPT99211 $75 Nov 15th 401
Provider Number
Health Number Version Date of Birth Accounting Number Pay. Prog Payee
3562583126 LD 1977 July 05
Referred By Facility No In-Patient Admission
Service Fee Number of Service Date Diagnostic Service Fee Number of Service Date Diagnostic
Code Submitted Services YR MO DY Code Code Submitted Services YR MO DY Code
$150 July 27
G140 $35 1 July 27
Z00 $40 1
Provider Number
QS
Health Number Version Date of Birth Account Number Pay. Payee
Prog
7541351548 Jan 1st 1986
Referred By Master In-Patient Admission
No
Service Fee Number Service Date Diagnostic Service Fee Numbe Service Date Diagnostic
Submitted of Submitted r
Code YR MO DY Code Code of YR MO DY Code
Servic
Servi
es
ces
A003A $87.35 1 21th jan
110
Provider Number
Health Number Version Date of Birth Account Number Pay. Payee
Prog
th
4152156521 May, 9 , 1970
Referred By Master In-Patient Admission
No
Service Fee Number Service Date Diagnostic Service Fee Numbe Service Date Diagnostic
Submitted of Submitted r
Code YR MO DY Code Code of YR MO DY Code
Servic
Servi
es
ces
18th, may
A003A
K003A
G030 $50
