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Contact Information  

* Contact First Name: n
* Contact Last Name: n
* Title: n
* Telephone Number: n
* Fax Number: n
* Email Address: n

Facility Information

 * Organization Name: n
 * Specialty: n
* Number of Doctors: n
* Mailing Address: n
Ste., Bldg, etc.: n
* City: n
* State: n
* ZIP: n

Enrollment Information

Medicare Number: n

Medicaid Number: n

NPI Individual Number: n

NPI Organization Number: n

Tax ID Number: n

Additional Details

nTransactions Desired:

837 - Inst Claims
837 - Prof Claims
835 - Remittance

Current Clearinghouse/Billing Service: n

* Current Practice Management System Being Used : n


Approximate Claim Volume by Payor (Monthly): n n n n n n n n
* Commercial: n
* BCBS: n
* Medicaid: n
* Medicare: n