20131002162228248
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Label Here Client) Ordering Site Information: Physician Information: Account Name: Professional Arts Center Neurology Suites 603/609 Address 1: 1150 NW 14th Street Suite 609 Address 2: City, State Zip: Miami, Florida, 33136 Phone: 305-243-6732 Ordering: Koch, Sebastian Degree: MD NPI: 1831155779 UPIN: Not on file Physician ID: Patient Information: Name: CASTELLANOS FiERRERA,MARLENE Gender: Female Date of Birth: 9/19/1951 Age: 62 Address: 1780 SW 6 ST APT 3, APT 3 City, State Zip: MIAMI, FL 33135 SSN: w-)a-9075 Patient ID: 20015193 Phone: 305-854-4214 Alt Controllil: 245758920BU 20015193 Quest Diagnosticsm Orders Code 7197 Responsible Party / Guarantor Information Name: CASTELLANOS HERRERA,MARLENE Address: 1 7 8 0 SW 6 ST APT 3 APT 3 MIAMI, Florida 33135 Phone: 305-854-4214 Relation to Patient: S e l f Insurance Information Primary Insurance: Carrier Code: Company Name: Address: Policy Number: Group Number: Primary Policy Holder / Name: Address: Relation to Patient: Test LYMPHOCYTE SUBSET PANEL 1 Dx MEDICAID MEDIPASS C PO BOX 7072 Tallahassee, Florida 32314-7084 2440097021 Insured: CASTELLANOS HERRERA,MARLENE 1780 SW 6 STARTS APT 3 MIAMI, Florida 33135 Self Quest Diagnostics PSC-Hold University of Miami PSC-Hold - University of Miami 334.3 Specimen Type Blood Employer Name: ABN: Worker's Comp: N Date of Injury: 28786-24575892(M Account #: 28786 LAB REF # 24575892Q8U Collection Date: Collection Time: Expected 10/2/2013 Page 1 o f 1
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Transcript of 20131002162228248
Label Here
Cl ient ) Ordering Site Informat ion: Physician Informat ion:Account Name: Professional Arts Center Neurology Suites 603/609
Address 1: 1150 NW 14th Street Suite 609Address 2:
City, State Zip: Miami, Florida, 33136Phone: 305-243-6732
Ordering: Koch, SebastianDegree: MD
NPI: 1831155779UPIN: Not on file
Physician ID:
Patient Information:Name: CASTELLANOS FiERRERA,MARLENE
Gender: FemaleDate of Birth: 9/19/1951
Age: 62Address: 1780 SW 6 ST APT 3, APT 3
City, State Zip: MIAMI, FL 33135
SSN: w-)a-9075Patient ID: 20015193
Phone: 305-854-4214
Alt Controllil: 245758920BU20015193
Quest Diagnosticsm
OrdersCode7197
Responsible Party / Guarantor InformationName: CASTELLANOS HERRERA,MARLENE
Address: 1 7 8 0 SW 6 ST APT 3APT 3MIAMI, Florida 33135
Phone: 305-854-4214Relation to Patient: S e l f
Insurance InformationPrimary Insurance:
Carrier Code:Company Name:
Address:
Policy Number:Group Number:
Primary Policy Holder /Name:
Address:
Relation to Patient:
TestLYMPHOCYTE SUBSETPANEL 1
Dx
MEDICAIDMEDIPASS CPO BOX 7072Tallahassee, Florida 32314-70842440097021
Insured:CASTELLANOS HERRERA,MARLENE1780 SW 6 STARTSAPT 3MIAMI, Florida 33135Self
QuestDiagnosticsPSC-Hold
University ofMiami
PSC-Hold - University of Miami
334.3Specimen TypeBlood
Employer Name:ABN:
Worker's Comp: NDate of Injury:
28786-24575892(M
Account #: 28786
LAB REF # 24575892Q8U
Collection Date:
Collection Time:
Expected10/2/2013
Page 1 of 1
