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
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Provider Summary
Indicative
Relationship
Capitation
Common Cap Rel
Effective
Termination
01/01/2021
Cap Relationships
Rec Type
Rel Type
Primary Provider
Capitalized Provider
Scheduled ID
Pool ID
Network
P
P
123456789
234567890
0001
0001
PPOGOLD
P
S
123456789
234567890
0002
0002
PPOGOLD
Common Global Cap Rel
Effective
Termination
01/01/2021
Global Capitation
Rel Type
Network ID
NWCR Prefix
Schedule ID
Pool ID
Adj Period
New Payee
Adj Period
Agreement ID
Effective
Termination
Termination Reason
C
Silver Network
NAVC
CGCLABSSCHED
Silver Pool
2
2
DFRAGREE
01/01/2021
C
Gold Network
US
3
3
DFRAGREE
01/01/2020
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