example - pa supervised w600000 carrier zyz 2000 hydra ... · charles zavier, md xmen billing...
TRANSCRIPT
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
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