Provider
Provider
Common Practitioner
Provider ID
NPI
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Summary
Provider
Summary
Provider ID:
CORE
Name:
CORE, DOC
Common ID:
--
NPI:
4650156015
Termination:
01/01/2021
Reason:
MOVE
Claims Information
Claim ID
Provider
Begin Date
Status
Total Charge
Claim Type
SubType
130670000100
Smith, Joe
01/01/2021
01 - Acce...
$1000.00
Medical
H
142500000200
Jones, Brian
02/15/2021
15 - Pend...
$200.00
Medical
M
130700000500
Smith, Joe
02/18/2021
11 - Pend...
$350.00
Medical
M
130900000600
Jones, Brian
03/21/2021
11 - Pend...
$250.00
Medical
M
External Address:
Yes
Taxonomy Code:
1234567891011
Status:
Participating
Type:
Medical Doctor
Specialty:
Family Doctor
Secondary Specialty:
Orthopedist
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Memo
Memo
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Provider Summary
Indicative
Relationship
Capitation
Indicative
Practice Type:
--
Preauth Required:
NA
Review:
--
Value Code 2:
--
Primary Language:
None
User ID:
--
Capitation Cycle ID:
--
Service Conversion Category:
--
ITS Tier Designation:
--
Value Code 1:
--
Networks
Network ID
Effective
Termination
PCP
NWPR Prefix
Agreement ID
Addresses
Effective date
01/10/2020
05/05/2021
02/04/2022
Sharing:
Yes
Address Sharing
Address ID
Lorem Ipsum Dolor
Lorem Ipsum
123456789101
Just another data
Just a data
123456789102
Just a data
Just another data
123456789103
Another data
Another data
Type:
Primary, Practice, Remit, Handicap, Directory
Primary
Mailing
Office:
539 E Zion Drive, New York, NY 10001
Mailing:
123 Main Street, New York, NY 10001
County:
New York County
County:
New York County
Phone:
(718) 954-4567
Phone:
(718) 123-4567
Hours
Services
Mo-Tu:
8:00 AM - 1 PM and 2:00 PM - 7 PM
Doctor's Office Visit
Th-Fr:
8:00 AM - 1 PM and 2:00 PM - 7 PM
Laboratory
Physical Therapy
Payment Information
Effective
Claim Payee
Capitated Payee
Termination
Termination Reason
01/01/2021
Self
Self
No available actions
No available actions
No available actions