EXAMPLE - PA SUPERVISED W600000 Carrier ZYZ 2000 Hydra ... · Charles Zavier, MD XMen Billing...
1
W600000 Carrier ZYZ 2000 Hydra Road New York, NY 10001 Wolverine, Hugo 10 17 1960 2619 Avenue North Brooklyn NY NY 11235 555 5555555 111 1111111 G3000000 Wolverine^^^Hugo Y4 9900V13972 Carrier ZYZ Signature on File 01 02 2020 431 454 01 03 2020 01 03 2020 01 20 2020 0B 272222 DQ Charles Xavier, MD 1666699999 REFX5PA016182-8^^^G2PHYAS^^^PWK09EAC00985621^^^NTEADD20200302 0 M5020 0B 944444 01 20 20 01 20 20 11 99213 A 70 24 1 9877777777 211111110 WH002345 70 24 222 2222222 Charles Zavier, MD XMen Billing Services 490 Western Ave 200 Shore Drive Jean, Gray PA Brooklyn NY 11235 Great Neck NY 12345 01/20/2020 1666699999 1666699997 987-65-4321 XFactor Tactical Support 94 Jamaica Drive Jamaica 11422 EXAMPLE - PA SUPERVISED X
Transcript of EXAMPLE - PA SUPERVISED W600000 Carrier ZYZ 2000 Hydra ... · Charles Zavier, MD XMen Billing...
W600000Carrier ZYZ2000 Hydra RoadNew York, NY 10001
Wolverine, Hugo 10 17 1960
2619 Avenue North
Brooklyn NY NY
11235 555 5555555 111 1111111
G3000000
Wolverine^^^Hugo Y4 9900V13972
Carrier ZYZ
Signature on File
01 02 2020 431 454 01 03 2020 01 03 2020 01 20 20200B 272222
DQ Charles Xavier, MD 1666699999
REFX5PA016182-8^^^G2PHYAS^^^PWK09EAC00985621^^^NTEADD20200302
0M5020
0B 944444
01 20 20 01 20 20 11 99213 A 70 24 1 9877777777
211111110 WH002345 70 24222 2222222
Charles Zavier, MD XMen Billing Services490 Western Ave 200 Shore Drive
Jean, Gray PA Brooklyn NY 11235 Great Neck NY 1234501/20/2020 1666699999 1666699997
987-65-4321
XFactor Tactical Support
94 Jamaica Drive
Jamaica
11422
EXAMPLE - PA SUPERVISED
X