Sue Brown

Identifier:53252345-01

Relationship:Wife

Gender:Female

Birth Date:01/01/1972

Effective	Termination	ID	Type	Name	Override	Assignment	Related Cap Entity	Source	Source Date
01/01/2019	12/31/2019	CORE     Provider Information Tax ID:   055221212   Type: Medical Doctor NPI:   4650156015   Taxonomy Code: -- Address Type:   P   Payee Name: Thomas, Marcus C. Address:   123 Main Street   Provider Entity: P   Building 1   Remittance Address: 123 Main Street   Suite 101     Building 1   New York, NY 10001-1101     Suite 101 Phone:   (718) 555-9866     New York, NY 10001-1101 Fax:   (718) 555-9865   Memo: --	MP					Normal	01/01/2019
01/01/2020		CORE	MP					Normal	01/01/2020

TOM Brown

Identifier:53252345-00

Relationship:Subscriber

Gender:Male

Birth Date:01/01/1972

Effective	Termination	ID	Type	Name	Override	Assignment	Related Cap Entity	Source	Source Date
01/01/2019	12/31/2019	CORE     Provider Information Tax ID:   055221212   Type: Medical Doctor NPI:   4650156015   Taxonomy Code: -- Address Type:   P   Payee Name: Thomas, Marcus C. Address:   123 Main Street   Provider Entity: P   Building 1   Remittance Address: 123 Main Street   Suite 101     Building 1   New York, NY 10001-1101     Suite 101 Phone:   (718) 555-9866     New York, NY 10001-1101 Fax:   (718) 555-9865   Memo: --	MP					Normal	01/01/2019
01/01/2020		CORE	MP					Normal	01/01/2020