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
IPAs
ID
Name
Effective
Termination
300121212
Physicians of Northern Jersey
01/01/2010
Covering Providers
Provider ID
Covering Provider Prefix
Agreement ID Override
Status
Effective
Termination
Termination Reason
00813412
0002
00825c
Include
01/01/2003
Sponsoring
ID
Name
Effective
Termination
00821165
COMLT72, COMFT75
01/01/2004
Provider Groups
ID
Name
Effective
Termination
IHMPGOLD0001
Main St Provider Group
01/01/2021
Referral Provider
Referral Provider ID
Referral
Provider Prefix
Status
Effective
Termination
00813412
0002
Include
01/01/2003
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