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
