Provider Info
Account ID
Provider Name
NPI
 
Tax ID
Website
Organization Management
LOI Accpeted:
 
MNDABAA accepted
Provider Type
 
Status
Is Primary
 
WC Opt
Facility Address MAP
first name
MI
Last Name
Phone
Ext
 
Fax
Email
Address Line 1
 
Address Line 2
City
State
Zip
zip 4
Mailing Address MAP
first name
MI
Last Name
Phone
Ext
 
Fax
Email
Address Line 1
Address Line 2
City
State
Zip
zip 4
Primary Address MAP
first name
MI
Last Name
Phone
Ext
 
Fax
Email
Address Line 1
Address Line 2
City
State
Zip
zip 4
Billing Address MAP
first name
MI
Last Name
Phone
Ext
 
Fax
Email
Address Line 1
Address Line 2
City
State
Zip
zip 4
Billing Address MAP
first name
MI
Last Name
Phone
Ext
 
Fax
Email
Address Line 1
Address Line 2
City
State
Zip
zip 4
Created by:
Alex
Created date:
23/06/2017 12:34
Last updated by:
Elon Musk
Last updated date:
05/09/2017 10:34